
Class JS&1M 
Book J 



GopyrightN 



COPYRIGHT DEPOSIT. 



DISEASES 

OF 



THE INTESTINES 



A TEXT-BOOK FOR PRACTITIONERS AND 
STUDENTS OF MEDICINE 



MAX EINHORN, M.D. 

PROFESSOR OF MEDICINE AT THE NEW YORK POST-GRADUATE MEDICAL 

SCHOOL AND HOSPITAL, AND VISITING PHYSICIAN AT 

THE GERMAN HOSPITAL, NEW YORK 



Second IRevisefc Edition 



NEW YORK 
WILLIAM WOOD AND COMPANY 

MDCCCCIV 







LIBRARY of CONGRESS 
Two Cepies Received 

MAR 12 1904 

Copyright Sntry 

CLASS o- XXc No. 

COPY B 



Copyright, 1904, 
BY WILLIAM WOOD AND COMPANY 



TO 

MY ESTEEMED FRIEND AND TEACHER 



ERNST VON LEYDEN, M.D. 

PROFESSOR OF MEDICINE IN THE UNIVERSITY OF BERLIN 



THIS BOOK 

IS RESPECTFULLY DEDICATED 



PREFACE TO THE SECOND EDITION. 



It affords me much gratification to see that my work on 
" Diseases of the Intestines " has found favor with the medi- 
cal profession. The entire issue being exhausted, a new 
edition of this book is herewith published. Yery few 
additions have been made to the original text, as the prog- 
ress in this branch of medicine within the last four years 
has been but scanty. I trust the present edition will meet 
with the same friendly reception as the first. 

Max Einhorn. 

New York, February 10th, 1904. 



PREFACE TO THE FIRST EDITION 



This treatise is a continuation of my work on "Diseases 
of the Stomach," the two together comprising the principal 
disorders of the digestive tract. In discussing the subject 
of the intestinal affections an effort has been made to follow 
the same lines laid down in my book on the stomach. The 
practical points regarding diagnosis and treatment are al- 
ways placed in the foreground. 

Although onr knowledge of diseases of the intestines has 
not made such rapid progress as that of morbid conditions 



vi PREFACE. 

of the stomach, much has likewise been achieved in this 
field. Surgery has made many successful advances. The 
elucidation of the intimate relation existing between func- 
tional disturbances of the stomach and of the intestines 
also marks an important step forward, especially as to 
therapy. 

While there are many excellent works on intestinal dis- 
eases by- German authors, the more recent English literature 
contains no monographs on this important subject. The 
medical encyclopedias, it is true, contain very instructive 
contributions on this topic, and among these Ewald's treat- 
ise on diseases of the intestines in the "Twentieth Century 
Practice of Medicine " is a most valuable acquisition. 

The present volume, it is hoped, will to a certain extent 
fill the void in American literature of a monograph on the 
affections of this portion of the digestive tract. The writer 
desires to express his indebtedness to Nothnagel, Eoseuheim, 
Boas, Fleischer, Ewald, Pick, Fowler, Treves, and Ailing- 
ham, whose works have been frequently consulted. He 
trusts that this book will prove of practical utility to the 
practitioner, and if it will aid him in more successfully 
treating this class of cases, the author's effort will be more 
than recompensed. MAX Einhorn. 

New York, April, 1900. 



CONTENTS 



CHAPTER I. 
Anatomy and Physiology. 

PAGE 

Anatomy, 1 

The Intestinal Canal (Intestinum), 1 

The Duodenum, . .1 

The Small Intestine, 4 

Structure of the Small Intestine, ..... 6 

The Large Intestine or Large Bowel (Intestinum Crassum), . 11 

Histology of the Large Bowel, 17 

Physiology, 18 

1. The Secretory Function or the Chemical Processes in the 

Intestines, 18 

2. Absorption 24 

3. Motion, 28 

CHAPTER n. 
Methods of Examination and Treatment. 

Examination, . . . 32 

Interrogation, 32 

Inspection, 34 

Proctoscopy, . 37 

Palpation, 40 

Percussion, 44 

Auscultation, 45 

Inflation of the Intestine with Carbonic Acid Gas or Air, . 45 

Injection of Water per Anum, 48 

Lavage of the Bowel, 48 

Examination of the Faeces, 49 

Treatment .77 

Diet, t . . 77 

Mechanical Procedures, . . 81 

Injections 81 

Massage and Gymnastic Exercises, . . . . .83 



vm . CONTENTS. 

PAGE 

Mechanical Procedures: 

Hydrotherapy, 83 

Electricity, 84 

CHAPTER HI. 

Acute and Chkonic Intestinal Catarrh. 

Acute Intestinal Catarrh, . . . . , . . .86 

Synonyms, .......... 86 

Definition, . „ . 86 

Etiology, 86 

Morbid Anatomy, 88 

Symptomatology, 89 

General Subjective Symptoms, 90 

Objective Symptoms, . 91 

Fever, 92 

Localization of the Catarrhal Process, 92 

Duration, . . . . , . . . . "; . . .93 

Diagnosis, 94 

Prognosis, 94 

Treatment, 94 

Chronic Intestinal Catarrh, 97 

Synonyms, 97 

Definition, 97 

Etiology, 97 

Morbid Anatomy, . 98 

Symptomatology, 101 

Objective Symptoms, 102 

Course, ........... 106 

Diagnosis, 106 

Prognosis, 107 

Treatment, 108 

Hydrotherapeutic Measures, 109 

Mineral Waters, 110 

Medicaments, . . . . . . • . .110 

CHAPTER IV. 
Dysentery. 

Dysentery, . • . . 113 

Synonyms, . . ~ . . . . . . . . 118 

Definition, 113 

Etiology, 113 

Morbid Anatomy, . . . . . . . . ,118 



CONTENTS. 



IX 



Dysentery : 

Symptomatology of Acute Dysentery, 
Symptomatology of Chronic Dysentery 

Course, 

Complications, . . . 

Diagnosis, 

Prognosis, 

Treatment of Acute Dysentery, 
Treatment of Chronic Dysentery, 



PAGE 

. 123 

. 126 

. 127 

, 127 

, 128 

129 

129 

131 



CHAPTER V. 




Ulceus of the Intestines. 




1. Duodenal Ulcer, 


. 133 


Synonyms, ........ 


. 133 


Definition, 


. . .133 


Etiology, ......... 


. 133 


Morbid Anatomy, ....... 


. 134 


Situation of the Ulcer, 


. 135 


Symptomatology, 


. 136 


Course, 


. 138 


Diagnosis, ........ 


. 138 


Prognosis, 


. 139 


Treatment, ........ 


. 139 


2. Embolic and Thrombotic Ulcers, . . 


. 140 


Pathological Changes, ...... 


. 140 


Symptoms, 


. 141 


Diagnosis, ... . 


. 143 


Prognosis, ......... 


. 144 


Treatment, ........ 


. 144 


3. Amyloid Ulcers, ........ 


. 145 


Diagnosis, ........ 


. 146 


4. Tuberculous Ulcers, . ...... 


. 146 


5. Syphilitic Ulcers, ........ 


. 149 


6. Toxic Ulcers, 


. 150 


Symptomatology, ........ 


. 151 


Diagnosis, ..,.♦,.. 


. 153 


Prognosis, . . . . . „ . , . , 


. 153 


Treatment, ......... 


. 153 


CHAPTER VI. 




Neoplasms of the Intestine. 




Malignant Growths, 


. 156 


Cancer, .......... 


. 156 



x CONTENTS. 

PAGE 

Cancer : 

Definition, . . . . , . • ' ■> • .156 

Etiology, . 156 

Location, . . . . . . . . . 157 

Morbid Anatomy, 158 

Symptomatology, 160 

Course, .169 

Diagnosis, 169 

Prognosis, 170 

Treatment, . . 170 

Sarcoma and Lympho-Sarcoma, . . . . . .172 

Benign Tumors of the Intestine, 173 

CHAPTER VII. 

Hemorrhoids. 

Hemorrhoids, . . . . 175 

Synonyms, . . . .175 

Definition, . . . . . . . , , . 175 

Etiology, .175 

Morbid Anatomy, 177 

Symptomatology, . . . . 180 

Diagnosis, 185 

Prognosis, 186 

Treatment, 186 

Radical, 191 

Complications, 195 

Prolapse of the Rectum, . . 195 

Fissure of the Anus, . . 199 

CHAPTER VIII. 

Appendicitis. 

Appendicitis, 202 

Synonyms, . . . • 202 

Definition, . . .202 

General Remarks, 202 

Etiology, 203 

Morbid Anatomy, 208 

Symptomatology, . . • 212 

Course, . . . . .'.."; 214 

Diagnosis, 220 

Differential Diagnosis, 221 

Prognosis, 222 



CONTENTS. xi 

PAGE 

Appendicitis: 

Treatment, 224 

Medical, 224 

Surgical, 227 

CHAPTER IX. 

Intestinal Obstruction. 

Introductory Remarks, 232 

Acute Intestinal Obstruction, 233 

Synonyms, 233 

Definition, . 233 

Etiology, 233 

Compression of the Intestine, 233 

Strangulation by Adhesions, 234 

Strangulation by Meckel's Diverticulum, . . . 236 

Volvulus, 238 

Obturations, 239 

Intussusception, 240 

Pathological Changes, 242 

Symptomatology, 244 

Objective Signs, 251 

Course, 253 

Diagnosis, 255 

Prognosis, 204 

Treatment, 264 

Medical, 264 

Surgical, 272 

Chronic Intestinal Obstruction, 272 

Etiology, 272 

Symptomatology, 275 

Complications, . . . . ' 282 

Course and Prognosis, 283 

Diagnosis, 283 

Treatment, . .284 

Operative Intervention, 286 

CHAPTER X. 

Nervous Affections of the Intestines. 

General Remarks, .288 

Motor Neuroses of the Intestines, 290 

Diarrhoea, 290 

Etiology and Symptomatology, 290 

Diagnosis, .295 



xii CONTENTS. 



PA.3E 



Diarrhoea : 

Prognosis, . 295 

Treatment, , ■ 395 

Constipation, 297 

Synonyms, ......... 297 

Definition, . . . . . . . . . . 297 

General Remarks, 297 

Etiology, 298 

Symptomatology, ........ 303 

Diagnosis, 308 

Prognosis, 310 

Treatment, 310 

Moral, 311 

Dietetic, . . . 311 

Mechanical, 312 



CHAPTER XL 

Nervous Affections of the Intestines. 

Motor Neuroses (Continued), 320 

Paralysis of the Intestines, 320 

Diagnosis, 321 

Treatment, 321 

Proctospasmus, or Spasm of the Rectum, 322 

Diagnosis, 323 

Treatment, 323 

Paresis and Paralysis of the Sphincters of the Anus, . . 323 

Diagnosis, 324 

Prognosis, 324 

Treatment, 304 

Peristaltic Restlessness of the Intestines, 325 

Definition, 325 

Etiology and Symptomatology, 325 

Diagnosis, 326 

Prognosis, 326 

Treatment, 326 

Meteorism, 327 

Etiology, . .327 

Symptomatology, . . 328 

Diagnosis, 329 

Prognosis, 329 

Treatment, 329 

Sensory Neuroses of the Intestines, ■ . . . . . .331 

Enteralgia, 332 



CONTENTS. xiu 

PAGE 

Enteralgia: 

Synonyms, ......... 332 

Definition, 332 

Etiology, 332 

Symptomatology, 333 

Diagnosis, 335 

Prognosis, 336 

Treatment, .......... 336 

Hypogastric Neuralgia, 338 

Treatment, 338 

Hyperesthesia, Paresthesia, and Anaesthesia of the Intestine, 339 

Treatment, 340 

Secretory Neuroses of the Intestines, 341 

Membranous Enteritis, 341 

Synonyms, . . 341 

Definition, 341 

History, 341 

Etiology, . . 345 

Symptomatology, . . . . . . . . 347 

Diagnosis, 349 

Treatment, 350 

Intestinal Neurasthenia, 353 

Diagnosis, . 354 

Treatment, 354 

CHAPTER XII. 

Intestinal Parasites. 

General Remarks, 355 

Protozoa, 355 

Amoebae, 355 

Sporozoa, 356 

Infusoria, 356 

Vermes, 357 

Cestodes (Tape Worms), 357 

General Remarks, . 357 

Taenia Solium, 360 

Taenia Saginata or Mediocanellata, 361 

Bothriocephalus Latus, Taenia Lata, or Pig Head, . , 363 

Taenia Nana, . 364 

Taenia Cucumeriua, 364 

Taenia Flavopunctata or Taenia Diminuta, . . . 365 

Treatment, 365 

Trematodes (Fluke Worms), . 368 



XIV CONTENTS. 

PAGE 

Trematodes (Fluke Worms) : 

Distoma Hepaticum or Liver Fluke, . . . . . 3^8 

Distoma Lanceolatum, 3(59 

Distoma Haematobium or Bilharzia Hsematobia, . . 370 

Nematodes (Round Worms), 371 

Ascaris Lumbricoides (Common Spool or Round Worm), . 371 

Diagnosis . . 373 

Symptoms, 373 

Prophylaxis, . 374 

Treatment, . 374 

Ascaris Mystax, 375 

Oxyuris Vermicularis, Awltail, Seat or Pin Worm, Maggot 

or Thread Worm, 375 

Symptoms, 376 

Diagnosis, 377 

Prophylaxis, 377 

Treatment, . . 377 

Anchylostoma Duodenale, Dochmius Duodenalis, or Stron- 

gylus Duodenalis, 378 

Symptoms, . . . . . . . . .380 

Course, ■. 381 

Diagnosis, . . . . 381 

Treatment, .'■".. 382 

Anguillula Stercorals, 382 

Anguillula Intestinalis, 382 

Trichocephalus Dispar, Whip Worm, .... 383 

Symptoms, 383 

Diagnosis, . . • . 383 

Trichina Spiralis, . . . . .... 385 

Prophylaxis, 386 

Treatment, ......... 386 



DISEASES OF THE INTESTINES. 



CHAPTER L 

ANATOMY AND PHYSIOLOGY. 

ANATOMY. 

The Intestinal Canal (Intestinum). 
The intestinal canal may be divided into two parts, the 
small intestine and the large intestine (Fig. 1). The small 
intestine (intestinum tenue) is about seven to eight metres 
long, the first portion being called the duodenum, the sec- 
ond the jejunum, and the third the ileum. With the ex- 
ception of the duodenum the small intestine lies for the 
most part inside the more fixed portion of the large intes- 
tine and is connected to the posterior abdominal wall by 
the mesentery. This broad membrane extends from above 
downward and from left to right, from the end of the duo- 
denum above to the ileocecal valve below, enclosing the 
jejunum and ileum along the whole of their extent. 

The Duodenum. 

The duodenum, so called on account of its length (being 

about twelve inches long), is, unlike the other parts of the 

small intestine, very definite in position and extent. It is 

that part which is not suspended by the mesentery. It is, 

further, the most fixed as well as the widest part of the 

small intestine, measuring one and one-half to two inches 
1 



* DISEASES OF THE INTESTINES. 

in diameter. It has a curved shape, somewhat resembling 
that of a horseshoe. It surrounds the pancreas and is 
divided into four parts : 

1. The superior horizontal portion (pars horizontalis 
superior) begins at the pylorus, lying at the level of the 
first lumbar vertebra, and runs slightly upward and back- 
ward toward the right until it reaches the right side of the 
vertebral column. It ends at the neck of the gall bladder, 
and is the most movable of the four portions. It is cov- 
ered by the two layers of the peritoneum which are contin- 
ued from the stomach, and by these it is completely sur- 
rounded. Above it lie the liver (quadrate lobe) and the 
gall bladder, below it is the pancreas, and behind it are the 
common bile duct and hepatic vessels. 

2. The descending portion of the duodenum, beginning at 
the neck of the gall bladder, is about twice as long as the 
first portion, and runs almost vertically to the second or 
third lumbar vertebra. It lies to the right of the lumbar 
vertebrae, and touches the right kidney. In front of it and 
crossing it almost at a right angle, runs the transverse 
colon. It is more fixed than the first portion. On its left 
side is the pancreas, and the common bile duct a little 
more posteriorly. Into this part of the bowel, and at its 
inner and back part, but four inches from the pylorus, the 
common bile duct and pancreatic duct enter. The portion 
at which these ducts enter, occasionally forms a small sinus 
(diverticulum or ampulla Yateri). 

3. The third part or the transverse portion is the longest, 
measuring about five inches. It extends from the base of 
the second or third lumbar vertebra on the right side 
obliquely across the spine to the upper part of the left side, 
ascending a little on its way. In front of it is found the 
lower layer of the transverse mesocolon. The superior 



ANATOMY 



mesenteric vessels cross this part of the duodenum, running 
between it and the pancreas in order to reach the mesentery. 
This portion is in relation with the pancreas and superior 




Fig. 1.— The Intestine, as Seen from the Front, after Removing the Omentum (Testut). 
1, Abdominal wall ; 2, wall of the thorax ; 3, oesophagus ; 3', cardia ; 4, stomach ; 4', 
pylorus ; 5, duodenum ; 6, pancreas ; 7, liver ; 8. gall bladder ; 9, gastrohepatic liga- 
ment ; 10, right kidney and its suprarenal capsule ; 11, small intestine ; 12, terminal 
portion of the ileum ; 13, caecum ; 13', its appendix ; 14, ascending colon : 15, transverse 
colon ; 16, descending colon ; 17, ileopelvic colon ; 18, bladder ; 19, parietal peritoneum ; 
20, spleen ; 21, diaphragm ; 22, thoracic aorta. 

Mesenteric artery above, with the vena cava, aorta, and 
crura of the diaphragm behind. It is the most fixed por- 
tion of the duodenum. 



4 DISEASES OF THE INTESTINES. 

4. The fourth part of the duodenum or second ascending 
portion ascends vertically at the left side of the spine. It 
is aboat one inch long and forms the end of the duodenum. 
It is firmly fixed in its place by the musculus suspensorius 
duodeni, the latter being the name of the fibrous band, 
containing some plain muscular fibres which descend to the 
vertical part of the duodenum from the left crus of the 
diaphragm and the tissues about the coeliac axis. It ter- 
minates at this point in the jejunum, forming the flexura 
duodenojejunalis at a place situated to the left of the sec- 
ond lumbar vertebra. 

The Small Intestine. 

The small intestine which forms the continuation of the 
duodenum is composed of the jejunum and ileum. There 
is really no marked structural difference between the two, 
and it is therefore hardly possible to determine where one 
ends and the other begins. As a rule, the upper two-fifths 
are designated as the jejunum and the lower three-fifths as 
the ileum. The jejuno-ileum fills the greater part of the 
abdomen. It occupies the umbilical, hypogastric, iliac, 
and lumbar regions, and is more or less encircled by the 
large intestine. The coils formed by the jejunum and 
ileum are very movable and completely invested by the 
peritoneum. They are supported and attached to the pos- 
terior parietes by the mesentery. The latter extends from 
the end of the duodenum to the ileocecal junction. The 
point at which the mesentery is attached above is on a level 
with the lower border of the pancreas and just to the left 
of the vertebral bodies. From this point of insertion the 
mesentery follows an oblique line running downward and 
to the right, crossing the great vessels and ending in the 
iliac fossa. The length of the mesentery from the spine 



ANATOMY. o 

to the intestines varies in different parts of the canal, its 
average being eight to nine inches. It soon attains its full 
length, and within one inch of the end of the duodenum is 
already six inches long. The small intestine hangs on 
the mesentery in the form of coils, and the folds which the 
mesentery forms may be compared to those of a fan. 

The small intestine including the duodenum has an aver- 
age length of about twenty feet. The calibre of the small 
intestine is larger at its upper end and gradually dimin- 
ishes in size until its entrance into the large boweL Thus 
at the beginning the jejunum has a circumferential calibre of 
17.5 cm., the ileum at its beginning of 11.5 cm., and at its 
end 9.5 cm. The ileum passes perpendicularly into the as- 
cending part of the colon just above the caecum, its mucosa 
forming a double valve, the valvula Bauhini. The jejuno- 
ileum is the most movable part of the intestinal tract. 
Wherever a free space is left it occupies it. It is therefore 
most often met with in hernias. During gravidity or when 
a tumor ur ascites exists in the abdomen the small intes- 
tine moves up higher and thus escapes compression. 

The small intestine receives its blood supply from the 
abdominal aorta. The arteria gastroduodenalis, a branch 
of the arteria hepatica, supplies the upper part of the duo- 
denum; the lower part of the duodenum and the jejunum 
and ileum are supplied by the arteria mesenterica superior. 
The latter vessel branches off into a fine net of numerous 
small vessels which run through the intestinal wall. The 
end ramifications penetrate the submucosa and here again 
form a net. From the latter the finest ramifications pene- 
trate the mucosa and form a capillary system of the villi 
and glands. The venous blood flows partly into the vena 
gastrica superior, partly into the vena mesenterica superior, 
and empties itself into the vena porta. The lymphatics 



& DISEASES OF THE INTESTINES. 

form a continuous series which is divided into two sets, 
that of the mucous membrane and that of the muscular 
coat. The lymph vessels of both sets form a copious 
plexus. They run between the two folds of the mesentery 
and end in the mesenteric lacteals. They are provided 
with valves which prevent the current from flowing back- 
ward, the direction of which is into the truncus lymphati- 
cus intestinalis and finally into the thoracic duct. 

The nerves of the small intestine originate principally 
from the plexus mesentericus superior or the sympathetic. 
The duodenum is supplied by the plexus hepaticus, a 
branch of the plexus cceliacus. The abdominal part of the 
vagus, namely, the plexus gastricus, anterior and posterior, 
also supplies the small intestine with nerves. The nerves, 
which are mostly non-medullary, enter the intestinal wall 
in connection with the branches of the arteria mesenterica 
superior and form a subserous net. They then penetrate 
the long muscular fibres and form between these and the 
circular muscular fibres ramifications which consist of nu- 
merous groups of multipolar cells (plexus mesentericus 
seu Auerbachii) ; fine branches of nerves arising here sup- 
ply the muscularis. Others penetrate the circularis, reach 
the submucosa, and form the submucous nerve plexus, 
containing small groups of ganglion cells (Meissner's nerve 
plexus) ; fine ramifications also supply the muscularis mu- 
cosae, the muscles of the villi, and end in the remaining 
part of the mucosa. 

Structure of the Small Intestine. 

The small intestine is composed of four principal coats : 
the serous, muscular, submucous, and mucous (Fig. 2). 
The serous coat is formed by the visceral layer of the peri- 
toneum. The muscular coat consists of an internal circular 



ANATOMY. 7 

and an external longitudinal layer (Fig. 3). The former 
is usually considerably thicker than the latter. They both 




Fig. 2.— Longitudinal Cross-section through the "Wall of the Small Intestine (Ileum). 
Solitary lymph nodules (nodulus lymphaticus solitarius). Intestinal glands (Lieber- 
kuehnii (Toldt). a. The mucous layer; 7). the muscularis mucosa? ; c, the submucous 
layer ; o\ the muscular layer ; e. the subserosa ; /, the serous layer ; g, intestinal villi : 
h, intestinal glands (Lieberkuehn) ; i, blood-vessels ; 7c a solitary lymph nodule ; 7, its 
centre. 

consist of bundles of unstriped muscular tissue supported 
by connective fibres. The submucous coat consists of con- 
nective tissue in which numerous blood-vessels and lym- 




1 & 




d---'- 




'^■'^™i-^'Gry<--; -ii<~: 



Fig. 3.— Longitudinal Cross-section through the Wall of the Duodenum. Brunner's 
glands (glandulae duodenales) (Toldt). a. The mucous layer ; o. the muscularis muco- 
sae ; c, the submucous layer ; d, the circular muscular layer ; e, the longitudinal mus- 
cular layer ; /, intestinal villi ; g, intestinal glands (Lieberkuehn) ; 7?, Brunner's duo- 
denum glands ; i, serous layer. 

phatics ramify. The mucous membrane is the most im- 
portant coat with regard to the function of digestion. It 



8 



DISEASES OF THE INTESTINES. 



consists of a very thin muscular layer (muscularis mucosae) 
containing circular and longitudinal fibres, the tunica 
propria of the mucosa, a tissue made up principally 

of reticular connective 
tissue with numerous 
leucocytes, glands, and 
the epithelial covering. 
The mucous membrane 
of the small intestine is 
of a grayish-red color 
and has a velvety ap- 
pearance. It possesses 
certain large folds of 
valvular flaps (valvulse 
conniventes Kerkringi) 
(Fig. 4). These are 
permanent crescentic 
folds of mucous mem- 
brane set transversely 
to the long axis of the 
intestine. Each one ex- 
tends from one-half to two-thirds of the distance of the 
lumen. The largest are more than two inches long and 
about one-third of an inch wide. They begin somewhat 
below the pylorus, are very large just below the entrance 
of the bile duct, remain conspicuous until the middle of 
the jejunum is reached, then become smaller and gradually 
disappear at the lower part of the ileum. They serve to 
increase the surface of the mucous membrane. 

The microscopical anatomy of the mucous membrane 
reveals the following : The entire inner surface of the small 
intestine is composed of villi, certain papilliform processes, 
.and glands ; an epithelial layer containing columnar epi- 




Fig. 4.— Jejunum Partly Opened (Toldt). a, 
Serosa ; 6, mucosa ; c, circular folds of Ker- 
kring. 



ANATOMY 



9 



thelial cells with a striated border, and some goblet cells 
cover the entire surface. The villi are formed principally 
by elevations of the tunica propria of the mucous mem- 
brane (Fig. 5). They are about 0.5 to 0.7 mm. in height 
and about 0.1 to 0.2 mm. wide and number almost ten mil- 
lions. Each villus possesses a centrally located space for 
chyle which is covered with endothelial cells and connected 
with the lymphatics of the intestinal mucosa. Each villus 
contains a perfect arrangement of blood-vessels and muscu- 
lar fibres which originate in the muscularis mucosa?. When 
rilling up with blood each villus expands, while under the 
contraction of its muscle it shrinks. Thus it is enabled to 
perform the function of suction and pumping. The villi 
form the main organ for 



m 



the 







the absorption 
small intestine. 

Around the villi lie 
their glands. First, 
there are tubular glands 
(of Lieberkiihn), and, 
secondly, acinous glands 
of Brunner. The former 
are similar in structure 
to the tubular glands in 
the stomach. They cover 
almost the entire surface 

of the whole small and large intestine. Each glandular 
tubule is about 0.3 to 0.4 mm. long and opens without 
forming any ramifications. They number over forty mil- 
lions and form the principal organ of intestinal secretion. 
Brunner' s glands are confined to the duodenum. They 
are most abundant at the commencement of this portion 
of the intestine, diminishing gradually as the duodenum 



Fig. 5. — Mucous Membrane of the Ileum with 
a Solitary Lymph Nodule (Toldt). a. In- 
testinal glands (Lieberkuehn) ; o, intestinal 
villi ; c, a solitary lymph nodule. 



10 



DISEASES OP THE INTESTINES. 



advances. They are situated beneath the mucous mem- 
brane and embedded in the submucous tissue. Each 
gland is a branched and convoluted tube lined with col- 
umnar epithelium. In structure they are very similar to 
the pyloric glands of the stomach, but are more branched 
and convoluted, and their ducts are longer. The duct of 

each gland passes through 
the muscularis mucosae 
and opens on the surface 
of the mucous membrane. 
Solitary follicles or 
glands are found scat- 
tered throughout the mu- 
cous membrane of the 
small intestine. They 
are most numerous in the 
lower part of the ileum. 
Each one has a diameter 
of from 3 to 6 mm. The 
structure of the solitary 
follicle is similar to that 
of the lymph nodes and 
consists of a dense reti- 
form tissue packed with 
lymph corpuscles and 
permeated by fine capillaries. There are no ducts. The 
interspaces of the retiform tissue are continuous with lar- 
ger lymph spaces at the base of the gland, by which they 
communicate with the lacteal system. The base of the 
nodules is in the submucous tissue. It penetrates the 
muscularis mucosae and enters the mucous membrane form- 
ing a slight projection of its epithelial layer. The solitary 
follicles are the breeding place of the lymph cells. They 




Fig. 6.— Ileum Partly Opened (Toldt). a. 
Solitary lymph nodules; b, serosa; c, 
mucosa. 



ANATOMY. 



11 



are met with in two conditions, namely, either scattered 
singly, in which case they are termed glandulse solitaries 
(Fig. 6), or aggregated in groups varying from one to three 






IpHraigisig 






Fig. 7.— Peyer's Patch (Noduli Lymphatici Aggregati) in the Ileum (Toldt). a, Peyer's 
patch ; b, solitary lymph nodules. 

inches in length and about one-half inch in width. The 
surface of the solitary follicles is free from villi. Chiefly 
of an oval form, their long axis is parallel with that of the 
intestine. In this state they are called glandulse agminatae 
or Peyer's patches or plaques (Fig. 7). They are almost 
always placed opposite the attachment of the mesentery. 
Peyer's patches number about twenty to twenty-eight. In 
some cases they are already found in the jejunum, but 
they are most prevalent in the ileum. 



The Large Intestine or Large Bowel (Intestinum Crassum).. 

The large intestine extends from the termination of the- 
ileum to the anus. It is about five to six feet in length. 
Its calibre decreases from beginning to end except at the 
ampulla of the rectum where it is larger. It measures 
28.5 cm. in circumference at the iunction of colon and cse- 



12 



DISEASES OF THE INTESTINES. 



cum, 20.5 cm. at the end of the ascending portion, 14.5 cm. 
in the descending portion. The large intestine is divided 
into the caecum, colon, and rectum. With the exception 

of the rectum 
it possesses 
three taeniae, 
these being 
groups of non- 
striated muscu- 
lar fibres run- 
ning lengthwise 
with the lumen 
of the intestine. 
Between the 
taeniae the walls 
are somewhat 
sacculated. The 
circular muscu- 
lar fibres are 
also accumulat- 
ed in spots, 
leaving short 
intervals be- 
tween each 
other, thus 
forming c o n - 
strictions and 
expansions (haustra coli) across the intestine (Fig. 8). 
The large bowel is further characterized by appendices 
epiploicae, external pouches, formed by the peritoneal cov- 
ering containing fat. The caecum is the head of the colon 
or that part of the large bowel situated below the mouth of 
the ileum (Fig. 9). It lies in the right iliac fossa and is 




6 f 

Tig. 8.— The Large Bowel Partly Opened along the Mesen- 
tery (Toldt). a, Free taenia; ft, taenia mesocolica; c, 
appendices epiploicae ; d, the mucosa ; e, the semilunar 
folds of the colon ; /, the mesocolon. 



ANATOMY. 



ia 



completely covered by the peritoneum. In the filled con- 
dition it. touches the anterior abdominal wall. Starting 
from the inner and back portion of the csecum lies the pro- 
cessus vermiformis or appendix, forming a narrow, some- 
what bent, blind-ending tube. The appendix is movable 
and has its own a 

mesentery (mes- /: 

enteriolum). 
Its length varies 
between 2 and 20 
cm. and its 
width between 
0.5 and 1 cm. 
The appendix 
opens into the 
csecum (ostium 
processus vermi- 
formis), occa- 
sionally form- 
ing a crescentic 
fold (v a 1 v u 1 a 
processus ver- 
miformis) . I n 
man it consti- 
tutes an entirely 
functionless or- 
gan which occa- 
sionally gives 
rise to manifold 

ailments. The appendix has no fixed position. J. I>. 
Bryant 1 found it most often "inward," then "behind the 
caecum," "downward and inward," "into the true pelvis." 
' J. D. Bryant : Annals of Surgery, February, 1893, p. 164. 




Fig. 9.— Section of the Caecum and Ileum, showing the En- 
trance of the Latter into the Caecum (Toldt). a, The 
semilunar folds of the colon ; b, c, the ileocaecal valves (b, 
the upper, and c, the lower one) ; d, the end portion of 
the ileum ; c, the posterior ileocaecal valve ; /, the appen- 
dicular valve ; y, the appendix. 



14 DISEASES OF THE INTESTINES. 

Without distinct demarcation the caecum merges into the 
ascending colon. It passes vertically above the crest of 
the ileum and runs along the posterior abdominal muscles 
and the lower part of the right kidney. At this point just 
in front of the kidney and immediately beneath the liver 
the colon bends toward the left of the flexura coli dextra. 
The ascending colon is posteriorly adherent through con- 
nective tissue with the jjarts just mentioned, while the 
peritoneum covers only its anterior and partly also its lat- 
eral surfaces. In close proximity to its median wall lies 
the ascending part of the duodenum. Beginning at the 
flexura coli dextra the colon runs across the abdominal 
cavity from right to left (transverse colon), forming the 
longest segment of the large intestine. It passes from the 
hepatic flexure in the right hypochondrium transversely 
and slightly upward from right to left along the anterior 
abdominal wall to the splenic flexure in the left hypochon- 
drium. This part of the colon is the most movable. It 
has a very long mesentery, called the transverse meso- 
colon. The usual position of the transverse colon corre- 
sponds to a line separating the umbilical and epigastric 
regions. It is in relation by its upper surface with the 
lower part of the liver and gall bladder, the greater curva- 
ture of the stomach and the lower end of the spleen; by 
its under surface with the small intestine ; by its anterior 
surface with the great omentum and abdominal wall; by 
its posterior surface with the transverse mesocolon ; on the 
right side with the second part of the duodenum, and on 
the left besides the latter with some convolutions of the 
small intestine. 

The transverse colon does not form a straight line con- 
necting the right and left flexures, but is about twice as 
long as this line and therefore forms several curves. In 



ANATOMY. 15 

the left hypochondrium especially, there is an S-shaped 
coil. The latter fills out the free space in the left hypo- 
chondrium which is left by the stomach in its various 
states of fulness. Beginning at the flexura coli sinistra 
the descending colon runs downward in front of the left 
kidney and the quadratus lumborum and iliac muscles un- 
til it reaches the left iliac fossa. The descending colon 
runs just in the opposite direction to the ascending colon, 
and like this is only partly covered bj r the peritoneum. 
The descending colon passes into the sigmoid colon or 
flexure (S Romanum), commencing above the iliac crest 
and ending below in the rectum at the brim of the true 
pelvis opposite the left sacro-iliac articulation. It is gen- 
erally described as an S-shaped curve having an upper 
colic rim turned toward Poupart's ligament and the lower 
rectal rim, hanging down into the true pelvis. It has a 
complete peritoneal covering or mesentery. This part of 
the bowel is very movable, and its calibre is the narrowest 
of that of the large bowel. The sigmoid flexure continues 
into the rectum, forming the terminal portion cf the intes- 
tinal tube. It runs, coming from the left, in front of the 
os sacrum down to the bottom of the small pelvis. Only 
the upper half of the rectum is invested completely with 
peritoneum (mesorectum) and is attached to the sacral ver- 
tebra. The lower half passes between the organs occupy- 
ing the pelvic floor, being adherent to them by connective 
tissue. It now runs posteriorly along the os coccyx and 
terminates in the anus. This part has an incomplete peri- 
toneal covering (plica Douglasii) lying anteriorly and turn- 
ing backward in order to ascend either over the vagina or 
the bladder (excavatio recto-uterina, excavatio rectovesica- 
lis). Below this point the rectum has very little mobility 
as it is covered all around by connective tissue. The en- 



16 DISEASES OF THE INTESTINES. 

tire rectum is about 18 to 22 cm. long. Its calibre varies. 
It is widest at the apex of the prostate, forming the am- 
pulla of the rectum. 

The longitudinal muscular fibres of the rectum are not 
arranged in taeniae as in the colon, but pass all around the 
lumen. The circular muscular fibres become more dense 
from above downward and increase to such a degree at the 
anal opening that they here form a thick ring (musculus 
sphincter ani internus). A short distance above this mus- 
cle there is also an accumulation of circular muscular fibres 
(musculus sphincter ani tertius). At the anus the walls of 
the rectum are connected with striated muscular fibres 
(sphincter ani externus and levator ani), which are both 
of importance in the act of defecation. 

The colon is supplied by the three arteriae colicae, 
branches of the arteria mesenterica superior and arteria 
mesenterica inferior. The arteria colica sinistra origi- 
nates from the arteria mesenterica inferior, while the ar- 
teria colica media and superior are tributaries of the arteria 
mesenterica superior. The veins accompany the artery and 
empty partly into the vena mesenterica superior, partly 
into the vena mesenterica inferior. The lymphatics of the 
colon are numerous and lie below the glands and all 
through the submucosa. The plexus mesentericus supe- 
rior, a branch of the plexus cceliacus, provides the nervous 
supply of the caecum, ascending colon, and the right half 
of the transverse colon. The plexus mesentericus inferior, 
a branch of the plexus aorticus abdominalis, supplies the 
left half of the transverse colon, the descending colon, and 
the sigmoid flexure. 

The rectum is supplied by the arteriae haemorrhoidales 
superior, media, and inferiores, branches of the arteria 
mesenterica inferior and arteria pudenda communis. The 



ANATOMY. 17 

venous blood of the rectum is carried to the venae hsemor- 
rhoidales principally into the vena mesenterica inferior, 
thus emptying into the vena portarum, partly, however, 
into the vena iliaca interna. In this way there is a sepa- 
rate communication (outside of the portal circulation) with 
the remaining vessels of the abdomen. The lymphatics of 
the rectum form a wide net, running partly to the glands 
lying behind the rectum, partly to the plexus lumbalis 
sinister. The nerves supplying the rectum originate from 
the sympathetic, being branches of the plexus mesenteri- 
cus inferior, the plexus sacralis (nervi hasmorrhoidales in- 
ferior and medii), and the plexus hypogastricus superior. 

Histology of the Large Bowel. 

The large bowel consists, like the small bowel, of four 
coats: the serosa, muscularis, submucosa, and mucosa. 
The structure of these four coats corresponds to that of 
the small intestine, except that the longitudinal muscular 
fibres are arranged in three groups (tamiaa) running along 
the wall, as mentioned above. The mucosa of the large 
bowel differs from that of the small intestine in that there 
is an absence of the folds of Kerkring and of the villi. 
Lieberkuhn's glands are here somewhat longer and some- 
times curved. 

The mucous membrane of the rectum is thicker, more 
red,, and succulent than that of the colon. There are nu- 
merous folds. One conspicuous fold is found 6 to 7 cm. 
above the anus (plica transversalis recti). In the neigh- 
borhood of the anus the folds take a longitudinal direc- 
tion, and are called columns Morgagnii seu recti. The 
lower region of the rectum contains the epithelial cells of 

the rectum, pavement-like epithelium, forming a gradual 

2 



18 DISEASES OF THE INTESTINES, 

transition from the mucous membrane of the digestive 
tract to that of the external skin. The upper portion of 
the rectum corresponds exactly to that of the colon. 

PHYSIOLOGY. 

The intestines are entrusted with the important office of 
digesting the food which has not been acted upon by the 
stomach, of absorbing it, and finally of eliminating the 
undigested remnants. In order to fulfil this object they 
have three functions, the secretory, absorbent, and motor. 
All these functions are supervised by ganglionic cells and 
nerves, the latter also transmitting sensory impressions. 

1. The Secretory Function or the Chemical Processes in the 

Intestines. 

As is well known, the intestinal secretion consists, first, 
of the bile; secondly, the pancreatic juice; and thirdly, the 
intestinal juice proper (succus entericus). The composi- 
tion of each of these and their properties may be found in 
the text-books on physiology, and also briefly in my book 
on "The Diseases of the Stomach." It will not be amiss, 
however, to describe here more fully their joint action in 
the intestinal canal. 

The effect of each of the digestive juices is influenced by 
that of the others. For this reason the chemical processes 
in the intestines are quite complicated. The carbohy- 
drates, whose conversion into maltose by the ptyalin has 
been checked in the stomach by the free hydrochloric acid, 
are now, after reaching the intestines, further changed by 
the diastase of the pancreatic secretion into maltose, which 
is further converted into glucose. Cane sugar is likewise 
converted into grape sugar, while milk sugar, according to 



PHYSIOLOGY. 19 

Voit and Lusk, 1 remains unchanged. The finer parts of 
the cellulose also undergo some changes, but their ulti- 
mate products are not known. It is certain, however, that 
under the influence of micro-organisms they partly undergo 
fermentation, giving rise to the formation of marsh gas, 
acetic acid, and butyric acid. 

The pancreatic juice forms the principal factor of all the 
digestive processes in the intestinal canal. Besides its ac- 
tion upon the carbohydrates through its diastatic ferment, 
it acts upon fats by means of the steapsin and upon al- 
buminates by means of the trypsin ferment. According 
to Nencki 2 and Eachf ord, 3 the fat-splitting action of the 
pancreas is greatly increased by the presence of bile. The 
splitting of the fats into fatty acids and glycerin is of 
greatest importance for absorption. The fatty acids com- 
bine with the alkalies of the intestinal and pancreatic 
juices and form soaps which are either absorbed as such 
or promote the absorption of fats. There is no doubt 
that the greater amount of fats taken in with the nourish- 
ment is absorbed as a fine emulsion in the formation of 
which the soaps take part. These processes of fat emulsi- 
flcation, by the action either of the pancreatic juice or of 
soaps, take place only in alkaline media. If the intestinal 
contents are acid, emulsification does not occur, or does so 
only at those places at which the fat comes in contact with 
an alkaline secretion covering the mucous membrane. Ac- 
cording to Claude Bernard 4 and Dastre, 5 the action of bile 
greatly increases the emulsifying property of the pancre- 

1 Lusk : Zeitschr. f. Biologie, Bd. 28, p. 275. 

2 Nencki : Arch. f. experimentelle Path. u. Pharm., Bd. 20. 

3 Rachford : Journal of Physiology, vol. 12. 

4 Claude Bernard : " Lecons de physiologie experirnentale, " 2d edi- 
tion, 1865. 

5 Dastre : Arch, de Physiologie, Tome 2, p. 315. 



20 DISEASES OF THE INTESTINES. 

atic juice. While the bile exerts a deleterious influence 
upon the action of pepsin in artificial solutions, its pres- 
ence in the stomach does not seem to have any inhibitory 
effect. The bile exerts an influence upon the digestion of 
the albuminates in the intestines by precipitating the pep- 
sin in the acid gastric contents. It thus destroys the ac- 
tion of the pepsin. This precipitate, formed by the gas- 
tric contents and the bile, is soon dissolved, partly through 
the intervention of freshly secreted bile in abundance, 
partly through the sodium chloride which arises after the 
neutralization of the gastric juice by the alkalies present. 
The action of the bile upon the pancreatic digestion of al- 
bumin is not deleterious, and may have a beneficial effect 
in the presence of organic acids which, as a rule, exist in 
the upper parts of the small intestine. 

Aside from the chemical processes caused bj r the enzymes 
in the intestines there also exist fermentative and putre- 
factive changes produced by micro-organisms. These are 
but very slight in the upper part of the intestine and 
increase in intensity toward the end of the small intestine 
and in the greater part of the large bowel, while they again 
decrease in the lower part of the bowel and in the rectum. 
According to Macfadyen, Nencki, and Sieber, 1 who have 
repeatedly analyzed the intestinal contents of a man with 
a fistula situated near the end of the ileum, only fermen- 
tative processes take place within the small intestine. The 
contents obtained in this case had a golden-yellow color 
and showed an acid reaction, the acidity amounting to one 
per mille. As a rule, they were odorless. The principal 
elements of the acidity consisted of acetic, lactic, and 
paralactic acids, volatile fatty acids, succinic acid, and 

1 Macfadyen, M. Nencki und N. Sieber : Arch. f. experimentelle 
Pathol, u. Pharm., Bd. 28, p. 311. 



PHYSIOLOGY. 21 

biliary acids; albumin, peptone, mucin, dextrin, sugar, 
and alcohol were present; leucin and ty rosin, however, 
were absent. Thus, according to these authors, fermenta- 
tive processes in the small intestine result merely from 
the action of microbes upon carbohydrates, which ac- 
tion ultimately leads to the formation of ethyl alcohol 
and the organic acids just mentioned. The latter pre- 
vent the putrefaction of albuminates within the small in- 
testine and also partly check the decomposition of the 
carbohydrates. 

The putrefaction of the albuminates takes place in the 
large intestine, the contents there having an alkaline reac- 
tion. The decomposition of the albuminates by the putre- 
factive processes caused by micro-organisms goes much 
further than that by the pancreatic digestion. The pan- 
creatic digestion of the albuminates gives rise to albumoses 
and peptones, lysin, lysatinin, proteinchromogen, amido- 
acids, and ammonia. In the putrefaction of the albumin- 
ates at first the same products are formed, but the decom- 
position advances still further and generates a host of new 
products: indol, skatol, paracresol, phenol, phenyl-propi- 
onic acid and phenyl-acetic acid, para-oxyphenyl-acetic 
acid, hydroparacumaric acid, volatile fatty acids, carbon 
dioxide, hydrogen, marsh gas, methyl mercaptan, and sul- 
phuretted hydrogen. In the putrefaction of gluten neither 
ty rosin nor indol is formed while glycocoll is developed. 
Of the products of decomposition just named some are of 
great importance, as they are eliminated by way of the urine 
after their absorption from the intestinal wall. Some of 
them, as for instance the oxy-acids, appear unchanged in 
the urine, others (like the phenols) after further oxidation, 
and still others (like indol and skatol) after combination 
with ethereal sulphuric acids. The presence of ethereal 



22 DISEASES OF THE INTESTINES. 

sulphuric acids in the urine is thus to a certain extent an 
indication of the amount of putrefaction going on in the 
intestine. The putrefactive processes in the intestine relate 
not only to the ingested food but also to the secretions 
rich in albuminates. Thus Miiller ■ observed that Cetti 
during his fasting period first showed a diminution of the 
amount of indican in the urine which entirely disappeared 
on the third day. The phenol elimination was also at first 
diminished, but beginning from the fifth day of fasting it 
commenced to increase, and on the eighth or ninth day 
reached an amount which was three to seven times that of 
a man under ordinary conditions. 

The putrefactive processes within the intestines, how- 
ever, do not reach that height which they attain outside 
of the body. Thus, for instance, the fresh contents of the 
large bowel do not present so fetid an odor as a pancreatic 
infusion or decomposing albumin would reveal after long 
standing. The putrefaction within the intestine is partly 
checked by several factors : 

1. Carbohydrates as such exert an inhibitory influence 
upon putrefaction (Hirschler 2 ); the organic acids which 
develop during their fermentation also partly check putre- 
faction. Of other foods, milk and kumyss, according to 
Schmitz, 3 likewise lessen the processes of bacterial de- 
composition, this effect being due to the presence of lactose 
and also of lactic acid. 

2. The bile exerts a decidedly anti-putrefactive action. 
As shown by Lindberger 4 and Limbourg, 5 albumin to 
which bile is added does not decompose so thoroughly as 

1 MlUler: Berl. klin. Wochenschr., 1887, No. 24. 

2 Hirschler : Zeitschr. f. physiol. Chemie, Bd. 10, p. 306, 

3 Schmitz : Zeitschr. f. physiol. Chemie, Bd. 17, p. 401. 

4 Lindberger: Maly's Jahresber. , Bd. 14, p. 334. 

5 Limbourg : Zeitschr. f. physiol. Chemie, Bd. 13. 



PHYSIOLOGY. 23 

without it. The biliary acids, moreover, inhibit putrefac- 
tion through their acid elements. 

3. Absorption. The rapid absorption of fluids from the 
intestinal wall and the forward motion of the contents do 
not permit the putrefactive processes to get the upper hand, 

These fermentative and putrefactive processes taking 
place within the intestines serve to augment the various 
means at the disposal of the organism to utilize or to break 
up into simpler components the more complex groups of 
various food substances. In the normal state these putre- 
factive processes are most probably checked before any 
deleterious substances can be developed. 

The intestinal contents on their long way from the duo- 
denum to the anus show the presence of different gases. 
These consist of traces of oxygen and a larger amount of 
nitrogen ; the latter is derived either from swallowed air 
which has come from the stomach, or from pure nitrogen 
which has been diffused from the tissues through the in- 
testinal walls. Carbonic-acid gas is present which has been 
developed through neutralization of the acid gastric con- 
tents by the pancreatic and intestinal juices, and also from 
the butyric and lactic acid fermentation of the carbohy- 
drates. Hydrogen is found in larger amounts after a milk 
diet and only in small quantities after a pure meat diet. 
Methyl mercaptan and sulphuretted hydrogen are present 
in traces, and undoubtedly owe their origin to the albumin. 
Marsh gas likewise results from the decomposition of 
albumin, but it is also evolved from the fermentation of 
carbohydrates, especially of cellulose. These different 
gases are formed and absorbed all along the intestinal 
walls, and most probably help to mix the contents and 
thus facilitate absorption. If present in too large quanti- 
ties, they are easily passed through the rectum; occasion- 



24 DISEASES OF THE INTESTINES. 

ally some of the gases contained in the upper part of the 
small intestine may be eructated by way of the stomach 
through the mouth. 

In passing through the large bowel the intestinal con- 
tents become thickened through the rapid absorption of 
the fluids, and at last are eliminated as fecal matter. This 
(faeces) comprises the remnants of the undigested material, 
excretory products of the intestines, and a host of micro- 
organisms. The quantity of fecal matter within twenty- 
four hours varies greatly according to the mode of nourish- 
ment. Thus after a mixed diet it amounts usually to from 
120 to 150 gm. After a vegetable diet, however, the quan- 
tity, according to Voit, 1 reached 333 gm. The reaction of 
the fasces is varied. Often it is found acid in their inner 
parts, while the outer surface shows an alkaline reaction. 
Their peculiar odor is principally due to Brieger's skatol, 
but also to indol and other substances. Their color is 
usually of a light or dark brown, according to the charac- 
ter of the nourishment. 

2. Absorption. 

The object of digestion is to dissolve and partially 
change the food substances into such combinations as can 
be assimilated by the blood. Before assimilation can be 
effected absorption must take place. The main place for 
the absorption of nutritive material is the small intestine. 
It will be best to describe the process of absorption of the 
different food materials separately. 

(a) The proteids are usually changed into albumoses 

and peptones before their absorption. Albumen as such, 

however, is also liable to be absorbed, although not so 

quickly as when its change into peptone has been accom- 

1 Voit: Zeitschr. f. physiol. Cheraie, Bd. 13. 



PHYSIOLOGY. 25 

plislied. The absorption of albumoses and peptones takes 
place through the intestinal wall by way of the capillaries 
of the blood-vessels and not through the lacteals. Thus 
Munk and Rosenstein ! observed in a patient with a lymph 
fistula that after a meal rich in albuminous food the lymph 
did not contain more proteids than before the meal. The 
peptones and albumoses do not reach the blood current as 
such, but are previously reconverted into albumin. This 
fact has been clearly shown by the experiments of Ludwig 
and Salvioli. 2 These investigators tied a resected intesti- 
nal coil at both ends and injected into its lumen a solution 
of peptone, while the coil was kept alive with defibrinated 
blood. Although the peptone entirely disappeared from 
the intestinal coil, the blood did not contain even traces 
of peptone. It therefore must have become changed into 
another substance. This change of the peptones into al- 
buminates before reaching the blood is of teleological im- 
portance. For, as has been shown by Schmidt-Muhlheim 3 
and others, peptone introduced into the circulating blood 
is soon eliminated with the urine. Where the change of 
the peptones into albuminates takes place and by what 
mechanism are not as yet certain. Some seem to believe 
that the epithelial cells of the intestinal walls perform this 
office, others that the leucocytes are the means of its con- 
version. 

The absorption of the albuminates appears to be more 
complete as regards animal than vegetable food. The 
reason for this is that the cellulose surrounding the legu- 
men partly renders its absorption more difficult. Again, 
the peristalsis being greater after vegetable food, the intes- 

1 Munk and Rosenstein : Virchow's Arch., Bd. 123. 

2 Ludwig and Salvioli : Du Bois-Reymond's Arch., 1880, Suppl. 

3 Schmidt-Muhlheim : Du Bois-Reymond's Arch., 1880. 



26 DISEASES OF THE INTESTINES. 

tinal contents pass through the canal quicker, and thus 
less of the albumen is utilized. And again, according to 
Hammarsten, 1 a part of the nitrogenous substances of the 
plant proteids appears to be indigestible. 

(b) The carbohydrates are absorbed principally as mono- 
saccharides. Glucose, laevulose, and galactose are absorbed 
as such. Cane sugar and maltose are ordinarily changed 
first into glucose and lsevulose. According to Yoit and 
Lusk, sugar of milk is not converted, and is either partly 
absorbed as such or else undergoes lactic-acid fermenta- 
tion. The different kinds of sugar are absorbed through 
the capillaries of the villi and thus reach the circulation. 
They enter the liver through the vena porta and are here 
retained in great part as glycogen. In case, however, a 
large quantity of sugar is at once absorbed, it may occa- 
sionally reach the lacteals and thus enter the blood current 
outside of the liver. In such instances sugar appears in 
the urine, a condition which is known as alimentary glyco- 
suria. The introduction of larger quantities of sugar into 
the intestinal tract occasionally gives rise to diarrhoea. 
Carbohydrates, however, even in large amounts in the form 
of starch, will be absorbed without difficulty and without 
giving rise to any trouble. 

(c) The fats. In the absorption of fats their emulsifica- 
tion seems to be of greatest importance. Although a small 
part is absorbed in the form of soaps, the greatest quan- 
tity of fat is taken up in the form of an emulsion. The 
latter comprises not only neutral fats but also fatty acids. 
These, however, undergo a change into neutral fats after 
their absorption from the intestinal walls. It is generally 
accepted that fats after their absorption from the intestinal 

1 Olof Hammarsten : " Lehrbuch der physiologischen Chemie," Wies- 
baden, 1895, p. 293. 



PHYSIOLOGY. 27 

wall directly reach the lymphatics and thus enter the tho- 
racic duct, whence they afterward find their way into the 
blood current. In a girl with a lymph fistula Munk and 
Rosenstein found that sixty per cent of the ingested fat 
appeared in the lymph. After giving the patient erucic 
acid (a fatty acid foreign to the organism) they could dis- 
cover thirty -seven per cent of this particular substance in 
the form of neutral fats. Thus it appears to be proven 
that while the proteids and carbohydrates after their ab- 
sorption directly reach the blood current, as mentioned 
above, the fats are an exception and directly enter the lac- 
teals. The ultimate way in which absorption takes place 
is not as yet known. It must, however, be accepted that 
the epithelial cells of the intestinal wall cause this process 
by some specific action. The absorptive property of the 
small intestine for fat is very great. According to Rub- 
ner, 1 a man can absorb over 300 gm. of fat per day. Not 
all kinds of fat, however, have the same coefficient of as- 
similation. Thus fats with a low melting-point (olive oil, 
goose fat, butter, etc.) are absorbed more quickly than 
those with a high melting-point (mutton fat and stearin). 
Moreover, free fats, like butter and lard, are assimilated 
more quickly and thoroughly than bacon, in which the fat 
is surrounded by connective tissue. 

Besides the above-named three groups of food sub- 
stances, water and different salts which are kept in solu- 
tion are very quickly and thoroughly absorbed all along 
the intestinal tract. Aside from the salts, other soluble 
substances of the secretory juices are also absorbed. Thus 
the urine contains traces of pepsin and also urobilin, 
which shows that the biliary products must have been 
absorbed and eliminated through the urine. According 
1 Rubner : Zeitschr. f. Biologie, Bd. 15. 



28 DISEASES OF THE INTESTINES. 

to Schiff , 2 the bile is absorbed from the small intestine 
and reaches the liver with the blood current in order to be 
eliminated again by this organ from the blood. 

The pancreatic juice being the principal factor in the di- 
gestion of the different kinds of food, it appears of interest 
to ascertain how much of these foods will be absorbed after 
the pancreas has been excluded from participation in the 
act of digestion. Minkowski and Abelmann 2 experimented 
on dogs by extirpating the pancreas, and found that forty- 
four per cent of the proteids and from fifty -seven to seventy - 
one per cent of carbohydrates (amylaceous food) were ab- 
sorbed, while the fats remained totally unabsorbed. The fat 
contained in milk, being emulsified, however, was absorbed 
to the extent of from twenty-eight to fifty-three per cent. 

While the main place at which the absorption occurs is 
the small intestine, the large bowel is also able to serve in 
this capacity. Thus aside from the absorption of fluids 
and salts which normally takes place in this organ, albu- 
minates and carbohydrates can be absorbed in consider- 
able amounts, and fats in small quantities. This function 
of the large bowel is of great practical importance, as it is 
utilized in some conditions for nourishing purposes (rectal 
alimentation). 

3. Motion. 

The motor function or peristalsis of the intestine has 
for its objects the thorough mixture of the contents and 
their propulsion through the entire canal until their final 
exit through the anus. Nothnagel 1 and Braam-Houk- 

1 Schiff: Pfliiger's Arch., Bd. 3. 

2 Abelmann : "Ueber die Ausnutzung der Nahrungsstoffe nach Pan- 
kreasexstirpation. " Inaug. Dissert. , Dorpat, 1890. 

3 H. Nothnagel : " Beitrage zur Physiologie und Pathologie des 
Darms, " Berlin, 1884. 



PHYSIOLOGY. 29 

geest l have studied the process of intestinal peristalsis in 
animals. After laparotomy the latter were kept in a bath 
of physiological salt-water solution of 38° C, and the mo- 
tions of the intestines were investigated. 

Three types of intestinal peristalsis were discerned: 1. 
The ordinary peristaltic motion. The intestinal tract con- 
tracts at a certain point and thereafter relaxes. The con- 
traction is carried with moderate rapidity for a certain 
length contiguously in the direction toward the anus and 
the contents are pushed forward. 2. Oscillating motions. 
An intestinal coil is here moved to and fro all along its 
mesentery without any particular contraction at any point. 
The contents are not propelled, but simply mixed up dur- 
ing these motions. 3. Rotary motions. A filled intesti- 
nal coil experiences a circular constriction which is rapidly 
carried over the intestine for the length of about 20 cm. 
This is exactly the same process as described under 1, but 
executed in a violent manner. 

While the first two types of intestinal peristalsis are 
purely physiological, the third type is partly pathological. 
It is met with only when the contents are mixed with a 
great deal of gas. Thus, after indiscretions in diet, we 
often feel this kind of rapid motion going along with a 
gurgling sound (tormina intestinorum) . This type is ob- 
served only in the small intestine, but never in the large 
bowel. 

The small intestine manifests much quicker peristalsis 
than the large bowel, the motions of which are very slow. 
Here the haustra during the act of peristalsis contract and 
then protrude in regular order. The small intestine while 
empty does not show any motion whatever, but after the 
entrance of chyme into the duodenum intestinal peristalsis 
1 Braam-Houkgeest : Pfltiger's Arch., Bd. 7, p. 266. 



30 DISEASES OF THE INTESTINES. 

begins. It is not, however, transmitted down to the Bau- 
hinian valve without interruption, but stops as a rule at a 
certain distance from its starting-point (about 20 cm.). 
After an intermission of some duration it begins again. 
Thus one or more intestinal segments may be in a state of 
peristalsis while other parts of the intestine in between are 
at rest. The time for the arrival of the first particles of 
chyme from the duodenum into the csecum is about two 
hours. But, of course, the intestinal peristalsis must con- 
tinue until the stomach has expelled the last portions of 
the chyme, that is to say, within about two hours after the 
stomach has become empty the small intestine as a rule 
will also be found free of contents. The forward motion 
of the contents in the large bowel is a very slow one in- 
deed. It takes as a rule from twenty to twenty -four hours 
for the fecal matter to move from the caecum to the rec- 
tum. 

Antiperistalsis, or reversed motion of the large bowel 
and the small intestine, beginning at the anus and extend- 
ing upward, has never been seen by Nothnagel in physio- 
logical conditions. 

The process of peristalsis is controlled by nervous influ- 
ences. Auerbach's and Meissner's plexus most probably 
contain automatic nerve centres for this act. But there 
are also other centrally located nervous agencies. Thus 
after great mental excitement diarrhoea very often results, 
showing that the intestinal peristalsis must have been 
greatly increased through the influence of the brain. 
There are also numerous nerves which supervise the motor 
function of the entire intestinal tract. Pfluger J has shown 
that the splanchnic nerve contains inhibitory fibres for the 

1 Pfli'iger : "Ueber das Hemmungs- und Nervensystem fur die peri- 
staltischen Bewegungen der Gedarme, " Berlin, 1857. 



PHYSIOLOGY. 31 

intestinal peristalsis. According to Ehrmann, 1 accelerat- 
ing and inhibitory fibres supervising intestinal peristalsis 
are contained in the vagus as well as in the splachnicus, 
but they have a varied function according to the way they 
end, whether in the longitudinal or in the circular muscles. 
The longitudinal muscles are stimulated by the splanchnic 
and paralyzed by the vagus. The circular muscles, on the 
other hand, are stimulated by the vagus and paralyzed by 
the splanchnic. 

Normally the chyrae acts as a stimulus on the intestinal 
canal and provokes peristalsis (through the influeDce of the 
nerves). Too cold drinks, indigestible food, organic acids 
(present in too large amount) may often cause an increased 
peristalsis and thus produce diarrhoea. Toxic substances 
which are ingested or developed from unwholesome food 
may have the same effect. 

1 Ehrmann : Wiener med. Jahrbiiclier, 1885. 



CHAPTER II. 

METHODS OF EXAMINATION AND TEEATMENT. 
EXAMINATION. 

Interrogation. 

The examination begins with a thorough interrogation 
of the patient. Before starting with the narration of the 
present ailment a general outline of previous sicknesses is 
of value. Diseases which involve the intestinal canal, like 
typhoid fever, dysentery, and the like, are of special impor- 
tance, as the} r are liable to be etiological factors in the de- 
velopment of consecutive ailments. The mode of living, 
with regard to habits (drinking, smoking, etc. ), should also 
be inquired into. 

The patient is then asked to describe his present com- 
plaint. He should state the time when the trouble began 
and its nature. If the chief complaint refers to pains, it 
is necessary to inquire as to their location and character. 
Pains felt in the neighborhood of the navel usually origi- 
nate in the small intestine ; those experienced in the right 
iliac region often emanate from the appendix ; while those 
in the left iliac region and in and about the rectum have 
their starting-point in the sigmoid flexure and in the lower 
portion of the rectum. Are the pains of long duration or 
do they last only a very short while, a few seconds or min- 
utes? The former variety is usually caused either by an 
affection of the sensory nerves of the intestines or by some 
organic lesion, like ulcers, etc. The latter variety, to which 






EXAMINATION. 33 

the name colic is applied, is due to a strong spasmodic 
contraction of a certain part of the bowel. Colicky pains 
are often followed and relieved by the passing of flatus or 
of fecal matter. Occasionally these pains also shift from 
one place of the abdomen to another, and the route of their 
travel is distinctly felt by the patient. 

Abnormal sensations, a feeling of heat or cold may also 
be experienced over a certain area of the abdomen. A fre- 
quent or constant desire for an evacuation (tenesmus) is 
encountered in dysentery and in many affections of the 
rectum. It is also advisable to inquire whether the pains 
and abnormal sensations appear at a certain period of the 
day or at a certain time after meals (soon after eating or 
three to four hours later), or whether they are experienced 
at night or especially in the early morning hours. 

The condition of the bowels should always be described 
in detail. Do the bowels act regularly and is the evacua- 
tion of sufficient quantity? What is its consistency? Is 
the stool of sausage-shape and pliable, or is it hard or very 
soft, mushy, watery ? "What is its color? Is it dark brown 
or light yellow or clay-colored or black? Is there an ad- 
mixture of mucus or blood? If there is constipation, in- 
quire whether the bowels move without any cathartics after 
a period of constipation of a few days, and if not, whether 
mild aperients are sufficient to cause an evacuation, or 
whether a strong drastic remedy is necessary. Does the 
constipation alternate with periods of normal movements 
or with periods of diarrhoea? Are the periods of constipa- 
tion, if cathartics are not resorted to, accompanied by any 
marked symptoms (headaches, dizziness, anorexia, etc.) 
or not? If there is diarrhoea, the patient should state how 
many movements a day he has. Is he disturbed during 
the night, or is the diarrhoea confined principally to the 



34 DISEASES OF THE INTESTINES. 

morning hours? Does the diarrhoea alternate with periods 
of constipation; does it disappear after a change of climate, 
or is it aggravated by mental excitement? Is there a feel- 
ing of exhaustion in connection with it? Is the abdomen 
rilled up with gas (meteorism)? Does this phenomenon 
pertain to a special part of the abdomen (the upper or 
lower region, right or left side), or does it extend over the 
entire abdomen? A feeling of tension in the abdomen 
with frequent passing of wind, belching, and flatus, is com- 
monly designated as flatulency. It is necessary to inquire 
whether this symptom is present principally at a certain 
time of the day or continuously. Absence of flatus is of 
significance if it occurs in conjunction with obstinate con-, 
stipation, otherwise it is of no consequence. 

In all intestinal disorders it is necessary to inquire as 
to the state of the stomach. The latter organ being in 
direct communication with the intestines, it will often be 
subject to disturbances in intestinal affections. Com- 
plaints of a bad taste and smell in the mouth are often 
made, principally in constipation. Anorexia and nausea 
are present in the most varied intestinal disorders. Vom- 
iting frequently occurs in intestinal obstruction. 

Inspection. 

Inspection of the abdomen is best made in good daylight 
with the patient in the recumbent posture, but should also 
be completed by inspection in the standing position. The 
condition of the skin of the abdomen is first examined. 
Sometimes striae or scar-like lines running parallel to each 
other over some part of the abdomen (especially the lower 
part) , and presenting either a silvery hue or, if not old, a 
rather reddish tinge, are observed; these are always signs 
of a very marked former distention of the abdominal pari- 



EXAMINATION. 35 

etes. Thus they are found after frequent pregnancies, also 
after the removal of rapidlj r developing abdominal tumors, 
or after tapping for ascites. These striae persist long after 
the disappearance of the conditions which caused their 
development. 

Distention of the abdominal veins, giving them a bluish 
hue, is observed whenever the return flow of the venous 
blood of the lower extremities is retarded either by in- 
creased intra-abdominal pressure (ascites, tumors of the 
abdomen) or by thrombosis or compression of the iliac 
vein or of the vena cava inferior. Cirrhosis of the liver 
and compression of the portal vein often produce the same 
result. In the latter condition there is an extensive forma- 
tion of veins over the navel which is commonly called caput 
Medusa?. After observing the appearance of the skin, the 
shape of the abdomen is then minutely considered. In 
normal conditions, in grown people, the abdomen and the 
chest are on the same level in the recumbent position. In 
small children the abdomen as a rule is somewhat more 
prominent than the thorax. In very old age the abdomen 
appears somewhat sunken. The greatest degree of a re- 
tracted or trough-shaped abdomen is found in stricture of 
the oesophagus or cardia, in basilar meningitis, and in 
lead poisoning. Long-continued inanition, no matter of 
what origin, also causes this phenomenon. 

Protrusion of the abdomen occurs either over a definite 
area or over the entire surface. The abdomen may pre- 
sent the shape of a round hemisphere or of a flattened one 
if there is an accumulation of air and gas in the intestines 
(intestinal meteorism). This occurs principally in atonic 
conditions of the intestines and in hysteria. A uniform 
protrusion of the abdomen or a general bloated condition 
is present in general peritonitis, occasionally also in pro- 



36 DISEASES OF THE INTESTINES. 

nounced atony of the intestines. In case of ascites, no 
matter to what cause it is due (tumors, cirrhosis of the 
liver, nephritis, etc.), the abdomen is also more or less 
evenly protuberant above, while the lower parts bulge out 
somewhat in the recumbent position. This is caused by 
the accumulation of fluid in the lower portions of the ab- 
dominal cavity. Change of posture alters the shape of the 
abdomen. This applies to the early period of ascites, 
during which the abdominal cavity is not yet filled to its 
maximum ; later, when this is the case, the abdomen ap- 
pears uniformly enlarged, and there is no bulging out of 
any particular portion. Change of position then no longer 
alters its shape. 

Protrusion of a certain part of the abdomen is noticed 
in many cases of neoplasm, sometimes in fecal concretions, 
and occasionally in appendicular abscesses. In umbilical 
hernia a small, more or less roundish protrusion is noticed 
in the region of the navel. In diastasis of the rectus ab- 
dominis muscles there appears in the middle line of the 
abdomen a long protrusion of sausage shape consisting of 
prolapsed intestine. Sometimes there is a pronounced 
protrusion of this area owing to the escape of a large mass 
of the bowel through the gap in the muscles. 

In patients with thin abdominal walls very small sau- 
sage-shaped prominences are occasionally visible which 
quickly change their configuration, appearing now in one 
place and now in another. This phenomenon is caused by 
peristaltic contractions of the small intestine. As a rule, 
they are not associated with pain and do not denote a mor- 
bid condition. Sometimes similar peristaltic waves in the 
small intestine appear periodically and annoy the patient. 
Here they may be caused by nervous influences. Peri- 
staltic contractions of the small intestine appearing in a 
violent manner and caused by a stenosis or an obstruction 



EXAMINATION. 



37 



of the intestinal lumen are usually much more pronounced, 
that is, the prominences are much higher and involve 
larger areas of intestine, the waves moving with greater 
rapidity and strength and being accompanied by intense 
pain. Visible peristaltic contractions of the large bowel 





FIG. 10.— Sims' Rectal Speculum. 



Fig. 11.— Allingham's Rectal Speculum. 



are ordinarily met with only in cases of partial or total 
intestinal obstruction. 

Inspection of the anal region is best made when the pa- 
tient lies on his side with his back toward the examiner. 
The buttocks are held apart with the hands, and thus thor- 
ough inspection of the anus is rendered possible. Piles, 
fissures, fistulas may thus be discovered. 

Proctoscojiy. — In order to inspect the anus internally and 
also the rectum it is necessary to introduce a speculum. 
This method of inspecting the rectum is called proctoscopy. 
Of the many specula devised for this purpose I would 
mention those of Sims, Allingham, and Kelly as the most 
practical (see Figs. 10, 11, 12). Kelly's speculum, which 
consists of a hollow metallic tube provided with an obtu- 
rator, is best suited for this purpose. Before inserting the 



SB 



DISEASES OF THE INTESTINES. 




instrument it must be thoroughly smeared with sweet oil 
or vaseline. In cases in which the rectal region is inflamed 
or ulcerated, it is necessary, in order to avoid too much 
pain, to induce anaesthesia of these parts by painting them 
with a ten-per-cent cocaine solution or by the introduction 

of a suppository 
of opium with 
belladonna or of 
cocaine. Re- 
cently Tuttle ' 
devised a new, 
very practical 
pneumatic proc- 
toscope. It is 
provided with a 
lamp at the end 
of the inspec- 
tion tube and 
also with an arrangement for inflation. Thus the rectum 
can be filled with gas when the examination takes place, 
and in this way a larger area of the canal becomes visible. 
It is hardly necessary to say that endoscopy of the rectum 
must not be performed until after a thorough evacuation of 
the bowels. It is best to wash out the gut before examin- 
ing with the speculum. When the speculum is in position 
a portion of the rectal mucosa becomes visible when good 
light is thrown into the endoscopic tube. The source of 
light is immaterial, although it is best to have electric 
light. Usually a small electric lamp with a reflecting mir- 
ror fastened to the head of the examiner best serves the 
purpose. The higher up the bowel has to be examined the 
longer the speculum must be. After the full insertion of 

1 James P. Tuttle: "Diseases of the Anus, Rectum, and Pelvic 
Colon," New York, 1902, p. 123. 



Fig. 12.— Kelly's Rectal Speculum. 



EXAMINATION. 39 

the instrument the highest portion of the bowel is first 
examined, and while gradually drawing out the speculum 
the entire area of the bowel through which it passes will 
be brought into view. Small ulcers, atrophic and congested 
conditions can thus be easily recognized and malignant 
growths detected at an early period. 

Transillumination. — Transillumination of the bowel was 
first suggested by myself ' and later practised principally 
by Heryng and Reichmann. 2 After a thorough cleansing 
of the bowel by means of high irrigation about one quart 
of water is injected and an electric illuminator (very similar 
in construction to the gastrodiaphane) is inserted into the 
rectum. The examination must be made in a dark room. 
By gradually pushing up the instrument successive portions 
of the bowel ma} r be transilluminated. This method, how- 
ever, has not as yet proven to be of any practical value. 

Roentgen- Rays.— The examination of the colon by means 
of Roentgen rays seems to be somewhat more promising. 
A soft-rubber rectal tube through which a flexible wire 
passes is introduced into the bowel as high up as possible 
and the patient exposed to the Roentgen apparatus. The 
wire within the tube becomes visible as a shadow, and thus 
marks the course of the bowel in which it lies. Inasmuch 
as it is hardly possible to insert an instrument higher up 
than the sigmoid flexure, the following procedure for the 
Roentgen examination appears to be of greater value : The 
bowel is filled with two quarts of water in which 60 gm. (2 
ounces) of subnitrate of bismuth are suspended by means 
of a starch solution. This mixture penetrates almost the 
entire colon, and thus the position of the large bowel can 
be determined b}^ the Roentgen rays. 

1 Max Einhorn . " Die Gastrodiapbanie. " New-Yorker medicinische 
Monatsschrift, November, 1889. 

2 Heryng und Reichmann : Therapeutische Monatshefte, 1892. 



40 DISEASES OF THE INTESTINES. 

Palpation. 

Palpation is the most important procedure available 
among the methods of examination in abdominal diseases. 
It is best performed in the recumbent position of the 
patient, the head being slightly raised and the abdominal 
muscles relaxed as much as possible. In order to effect 
this the room must be of a comfortable temperature and 
the hands of the examiner warm. If the patient is fidgety 
and contracts his abdominal walls, it is necessary to talk 
to him and to draw his attention away from the exam- 
ination. I have often noticed a great relaxation of the 
muscles during an expiration following a deep inspira- 
tion. Whenever, therefore, it is difficult to obtain relaxa- 
tion of the abdomen I tell the patient to take a deep 
inspiration and then make use of the following period of 
expiration for palpation. If all these means fail to relax 
the abdominal muscles, palpation may be tried in a warm 
tub bath, as first recommended by Chlapowski, or under 
chloroform narcosis. In cases of great diagnostic impor- 
tance the latter method is certainly preferable. In palpat- 
ing the abdomen it is advisable first to examine with the 
entire palm of the hand, applying very little pressure, thus 
determining the state and consistency of the abdomen. 
The hand may thus be passed over the entire abdominal 
surface from one place to another. This having been done, 
palpation is then performed with a trifle more pressure, the 
finger tips being used for this purpose. The latter procedure 
serves for exploring a more circumscribed area. Finally, 
deep palpation is practised for which considerable pressure 
may be required. 

Palpation aids us in discovering the position of some of 
the abdominal organs. With regard to the intestine the 



EXAMINATION. 41 

following portions are often accessible to this method of ex- 
amination : the caecum and part of the ascending colon, the 
transverse colon, and the sigmoid flexure. In some in- 
stances the descending colon above the sigmoid flexure can 
also be palpated, especially if it is filled with hard scybala. 
The jejunum and ileum filling most of the lower part of the 
abdominal cavity (from the navel downward) cannot nor- 
mally be separately outlined. 

For the detection of tumors in the abdomen palpation is 
of great service. By means of it we gain information with 
regard to their size, shape, and consistency. An uneven 
protuberant surface is characteristic of malignant growths, 
while an even surface is more often found in benign neo- 
plasms or in intussusception. A fecal tumor can be recog- 
nized by indentations made by pressure with the fingers. 
Sometimes after such pressure it is possible to notice for a 
moment, when raising the finger, a slipping off of the in- 
testinal wall from the fecal mass. This phenomenon, first 
described by Gersuny ' under the name of " Klebesymptom, " 
I have observed quite frequently and consider of practical 
value. 

Another important object of palpation is to ascertain 
whether there is tenderness or pain on pressure. While 
strong pressure exerted upon the intestine through the ab- 
dominal wall even normally elicits an unpleasant sensation, 
there is, however, no distinct pain connected with this act. 
Tenderness on slight pressure is often present in inflam- 
matory conditions of the bowels and also in ulcerative 
processes. A circumscribed pain on pressure is present 
in the appendicular region (McBurney's point) in appen- 
dicitis, especially in the acute form. In chronic appendi- 
citis the pain may be elicited only upon very strong press- 
1 Gersuny : Wiener klinische Wochenschrift, 1896, No. 40. 



42 



DISEASES OF THE INTESTINES. 




FULL SIZE %;, 

G. TIEMANN & CO., N. Y. 
Fig. 13.— Finger Cot. 



ure. In ulcerations of the bowel there may be also one 
or several circumscribed areas very painful to pressure. 
In pains due to a purely nervous affection of the bowel 

pressure may afford 
relief. If a mere 
touching of the ab- 
domen elicits pain, 
it is a sign either of 
an extensive inflam- 
matory process with- 
in the bowel or of 
peritonitis. 

Palpation in the 
form of tapping oc- 
casionally produces a splashing sound (clapotage) over 
some portions of the bowel. The splashing sound can be 
elicited over the colon only when it is filled with liquid or 
semi-liquid matter and gas. It can be discovered off and 
on either in the caecum and in the portion of the bowel im- 
mediately above it or in the sigmoid flexure. In the small 
intestine clapotage can be obtained only in the dilated 
portion of the gut above a stricture. Boas ] first suggested 
the method of filling up the bowel with from 500 to 600 
c.c. of water and then examining for the splashing sound 
along the colon. When the patient has been thus pre- 
pared, clapotage can be produced in the sigmoid flex- 
ure ; and by having the patient turn on his right side, it 
can occasionally be produced in the transverse colon, and 
finally in the caecal region. In cases of atony of the bowel 
Boas was able to evoke the splashing sound even after 
the injection of only 200 to 300 c.c. of water. Frieden- 

1 Boas : " Diagnostik und Therapie der Magenkrankheiten, " Theil i., 
1897, 4te Auflage, p. 105. 



EXAMINATION. 



43 



wald 1 has also practised the same method with advan- 
tage. Whenever the splashing sound can be produced in 
the colon it serves the purpose of determining the situa- 
tion of this organ. 

The rectum is best palpated with the index ringer well 
oiled or smeared with vaseline or encased in a rubber cot 
(Fig. 13) and anointed in the same 
way. The condition of the anus and 
the lower portion of the rectum can 
be advantageously investigated with 
the ringer. The examination may be 
made either in the recumbent posture 
of the patient, in the side or knee- 
elbow position, or in the standing po- 
sition. In the latter instance it is 
well to have the patient exert down- 
ward pressure upon the rectum. 
Hemorrhoids, polypi, and malignant 
growths can thus be occasionally dis- 
covered. In cases in which there is 
a suspicion of malignant growths in- 
volving portions of the colon not ac- 
cessible either to palpation by the 
ringer or inspection with the procto- 
scope, examination with the entire 
hand in chloroform narcosis can be 
tried as first practised by Simon. 2 
After dilating the anal sphincters, the 
entire right hand and the arm are inserted into the bowel 
through the anus, and thus the higher portions of the 




Fig. 14a. Fig. 15. Fig. 14b.. 

Figs. 14a and 14£>.— Cylin- 
drical Bougies. 

Fig. 15.— Olive-Point Bou- 
gie. 



1 J. Friedenwald : Medical News, 1894. 

2 Simon ; Verhandlungen der deutscben Gesellsch. f. Chirurgie, 1871,. 
and Deutsche Klinik, 1872. 



44 DISEASES OF THE INTESTINES. 

<?olon palpated with the fingers. This method can be rec- 
ommended only in cases of extreme importance, as such 
an examination is liable to produce unpleasant symptoms, 
.as, for instance, incontinence of the rectum, tearing of the 
mucous membrane, etc. 

Palpation of the rectum by means of sounds is performed 
whenever there is suspicion of a stricture involving por- 
tions of the bowel not accessible to examination by the fin- 
ger. For this purpose either bougies (see Figs. 14 and 
15), or, still better, rectal tubes of various calibre may be 
employed. Kuhn ' has recently recommended the use of 
tubes provided with a metal spiral. He believes that 
these penetrate the colon farther up without bending. 
His statements have, however, not as yet been corroborated. 

Percussion. 

Percussion is of less importance than palpation. In 
many instances it serves to confirm the results obtained 
by the latter. In percussing the intestines it is best to 
use the fingers. It should be done rather gently. Mild 
percussion permits the discernment of slight differences 
of sound much better than strong percussion. As is well 
known, percussion over empty intestinal coils or those 
filled with gas or air gives a tympanitic sound which is 
louder over the large than over the small bowel. Intestinal 
coils filled with liquid or solid substances give dulness. 
In meteorism of the intestines percussion will elicit a tym- 
panitic sound of a deeper pitch than normally, and there 
will be besides some areas of dulness over the abdomen. 
The region of the liver and spleen will here show normal 
conditions with regard to the percussion sounds. Meteor- 
ism of the abdomen as a result of perforation will manifest 
1 Kuhn : Deutsche med. Wochenschr. , 1897, Nos. 36 and 37. 



EXAMINATION. 45 

an evenly diffused tympanitic sound all over the abdomi- 
nal cavity. Usually the dulness over the region of the 
liver and spleen will have disappeared. In ascites percus- 
sion will reveal an area of dulness in the lower parts of the 
abdomen, and there will be a change in the character of 
the sound on altering the position of the patient. Tumors 
of the intestine give dulness on percussion. Fecal accu- 
mulations and appendicular abscesses will also manifest 
dulness on percussion. 

Auscultation. 

Auscultation is not of great significance in diseases 
of the intestine. Palpation of intestinal coils with the 
application of moderate pressure may elicit either a gur- 
gling noise or a friction sound. The latter was formerly 
believed to be pathognomonic of typhoid fever. Of late, 
however, it has been recognized that this sign is found in 
many other conditions. At the time of active peristalsis 
all kinds of gurgling sounds are heard within the intestine 
(borborygmi), which, however, are not of much impor- 
tance. In chronic stenosis of the intestine very loud noises 
are at times heard, caused by the sudden passage of liquid 
and gaseous contents through the stricture under great 
pressure. In the latter affection splashing sounds can also 
be easily produced over the enlarged bowel above the stric- 
ture. Often a tympanitic sound of a metallic character can 
be heard. 

Inflation of the Intestine with Carbonic Acid Gas or Air. 

Inflation of the intestine is one of the most important: 
diagnostic procedures. Von Ziemssen, 1 who first intro- 
duced this method of examination, injected successively 

1 Von Ziemssen : Deutsches Archiv f. klinische Medicin, 1883, Bd. 
33, S. 235. 



46 DISEASES OF THE INTESTINES. 

into the bowel two solutions, one containing tartaric acid, 
the other bicarbonate of sodium in water. The carbonic 
acid gas developing fills the large bowel, which can then 
be recognized by the tympanitic percussion sound, or, in 
rare instances, by inspection. Schnetter, 1 of New York, 
suggested filling the bowel with carbonic acid gas by means 
of a tube attached to an inverted siphon containing soda- 
water, the valve of which is pressed. Here the carbonic 
acid gas runs into the bowel without any admixture of 
water. Rosenbach 2 made use of liquefied carbon dioxide 
from a sparklet. Instead of the latter Euneberg 3 recom- 
mended inflation of the intestine by means of air. This 
is best done by a rectal tube to which a compressible air 
suction bulb is attached. The advantage this method offers 
consists in the possibility of regulating the amount of the 
introduced air. In order to be able to measure the amount 
of insufflated air, Damsch 4 has recommended the employ- 
ment of a syringe of known capacity. An ordinary bicycle 
pump can be used for this purpose, the rectal tube being 
attached to it. 

Inflation of the bowel is of importance in detecting 
a stenosis of this organ. Under ordinary conditions the 
injected air evenly distends the entire colon, as can be 
proven by inspection and percussion. In case there is a 
stenosis in the large intestine the air will distend prin- 
cipally that portion of the bowel below the stricture, while 
that above will remain unchanged. It is thus possible to 
recognize the seat of a constriction. The significance of this 
diagnostic means, however, is confined merely to strictures 

1 Schnetter : Deutsches Archiv f . kliniscke Medicin, 1884, Bd. 34, 
S. 638. 
2 0. Rosenbach: Berliner klinische Wochenschrift, 1889, No. 28. 
3 Runeberg: Deutsches Archiv f. klinische Medicin, Bd. 34, S. 460. 
4 Damsch: Berliner klinische Wochenschrift, 1889, No. 75. 



EXAMINATION. 47 

of a high degree, while a beginning stenosis of the bowel 
cannot be thus recognized, as the air will pass through it. 

The position of the colon can be ascertained by this pro- 
cedure. Normally the transverse colon is situated some- 
what above the navel, while in cases of enteroptosis it may 
be found about a hand's width above the symphysis. 

Inflation of the colon is also of importance in the 
differential diagnosis of abdominal tumors. As is well 
known, tumors of the intestine will become more distinct 
after inflation of the bowel with air, while tumors of the 
kidney, of retroperitoneal glands, and of the spine tend to 
recede. According to Minkowski, 1 abdominal tumors after 
filling the colon with air or water are usually slightly 
shifted in the direction of the organ to which they be- 
long. 

Inflation of the bowel with air impregnated with ether 
has been suggested by Dr. Sutton 2 as a means of recog- 
nizing intestinal perforation. For this purpose he makes 
use of a bottle filled with two drachms of ether. The bot- 
tle is provided with a perforated rubber cork to which are 
attached two rubber tubes provided with stopcocks. One 
of these is then attached to a bic3^cle pump and the other 
to an ordinary rectal tube. The air pumped into the bowel 
must pass through the bottle containing ether and thus 
takes up the ether vapors. In case of perforation of the 
bowel, the ether quickly escapes through the opening into 
the abdominal cavity and equally distends it; while, if 
there is no perforation, the bowel, first the large and later 
the small intestine, becomes filled with air and ether ; ulti- 
mately the ether reaches the stomach and is usually eruc- 

1 Minkowski : Berliner klinische Wochenschrift, 1888, No. 31. 
2 E. M. Sutton: " Diagnosis of Intestinal Perforations by Means of 
Ether Inflation per Rectum. " Journal of the Am. Med. Assn. , Decem- 
ber 30th, 1899. 



48 DISEASES OF THE INTESTINES. 

tated. The ether can then be recognized by its charac- 
teristic odor. It seems that this procedure is especially 
useful in gunshot wounds of the abdomen. 

Injection of Water per Anum. 

This is done by means of a rectal tube and a fountain 
syringe provided with a scale indicating the amount of 
water used. In case of stricture, especially of the lower 
portion of the colon, the quantity of water which can be 
injected is not great, while ordinarily from three to five 
quarts of water can be poured in. Inasmuch as even nor- 
mally some people are not able to hold large amounts of 
water in the bowels without experiencing considerable dis- 
comfort, the quantity of fluid which can be injected with- 
out pain is not of great diagnostic value. Filling up the 
bowel with water can also be made use of for the determi- 
nation of the position of the colon, as this organ will then 
give a dull sound. For this purpose, however, the proced- 
ure in question is not so good as the above-described method 
of inflation with air. 

Lavage of the Bowel. 

Lavage of the bowel in a similar manner as performed 
in the stomach has been recommended by Boa3 1 for di- 
agnostic purposes. It is best performed in the lateral 
posture of the patient after an evacuation of the bowels. 
The same apparatus as for gastric lavage may be used 
here. The rectal tube, which represents the stomach tube 
employed in gastric lavage, is attached to a long piece 
of rubber tubing provided with a big funnel. The rectal 
tube is inserted as high up in the bowel as possible and 
then the water is poured in until the patient begins to 
feel some discomfort. As soon as this is the case the fun- 
1 J. Boas: Deutsche Aerzte-Zeitung, 1895, Nos. 2 and 3. 



EXAMINATION. 49 

nel is lowered and thus the water returns. The latter is 
now subjected to a thorough examination. Normally the 
returning water appears pretty clear or slightly turbid by 
the admixture of small particles of mucus, epithelial cells, 
and fecal matter. In catarrh of the large bowel a consid- 
erable quantity of mucus is found. Ulcerative processes 
accompanied by hemorrhages or by suppuration are often 
recognized by the admixture of either pus or blood in the 
wash-water. Occasionally exfoliated pieces of intestinal 
mucosa are found in the wash-water, and a microscopical 
examination of them may be of diagnostic importance. 

Examination of the Fceces. 

The examination of the faeces is of much service in dis- 
eases of the intestine. The faeces represent the end pro- 
duct of the digestive act, consisting of residue unsuitable 
for further assimilation. It is evident that a thorough 
knowledge of the dejecta will throw light upon the nature 
of the activity of the intestines. 

The normal faeces consist of changed and unchanged 
remnants of food, bacteria, traces of digestive juices, epi- 
thelial cells, and salts. The quantity of the faeces for 
twenty -four hours varies greatly with the kind of food 
taken. In a mixed diet it usually amounts to from four to 
seven ounces. The color of the faeces is usually dark brown 
owing to changed bile pigment, the bilirubin having be- 
come changed in the intestine into urobilin. The diet has 
great influence upon the color of the faeces. Meat pro- 
duces a dark brown, milk a light yellow color, cacao a 
more or less brownish-red, huckleberries and claret a dirty 
black-brown color with a greenish hue. The salts of iron 
and manganese give rise to a darker color than the usual 
one, while bismuth produces a more or less blackish color. 
According to Quincke, all these metals are reduced to 



50 DISEASES OF THE INTESTINES. 

oxydule combinations which are responsible for these 
colors, 1 while the former belief that these metals formed 
sulphides is not correct. Calomel frequently produces a 
greenish hue. while senna, santonin, gamboge, and rhubarb 
give rise to an intensely yellow color. 

The faeces are normally somewhat soft in consistency and 
have a sausage shape. In abnormal conditions the con- 
sistency may be changed in two directions. The dejecta 
may be greatly hardened and appear in small balls, or in 
the form of very thin cylinders. On the other hand, the 
stools may be abnormally mushy or even liquid. The 
hardened stools which occasionally show grooved impres- 
sions from the taenia coli bear testimony to their long 
sojourn in the intestine, thus being exsiccated from the 
complete absorption of water. They are, however, by no 
means characteristic of a stenosis of the intestine. Very 
soft dejecta may be either watery, as for instance in 
cholera nostras or asiatica, or they are mixed with mucus 
which can be easily seen when pouring the dejecta into a 
glass and inverting it, when the mucus as a rule adheres to 
the surface of the vessel. 

Odor. — The characteristic odor of the faeces is normally 
caused by skatol and also to a less degree by indol. The 
fecal odor may be increased whenever the faeces have been 
retained much longer than normally in the intestine. On 
the other hand, faeces occasionally present very little or no 
odor when their sojourn in the intestine has been very 
short. As a good instance of the latter variety the so- 
called rice-water movements in cholera nostras and cholera 
asiatica may be mentioned. Movements with a fetid odor 
occur principally in malignant growths of the large bowel 
accompanied by ulcerative processes. 

Remnants of Food in the Fceces. — Undigested remnants of 

1 Quincke : Mtinchner medizinische Wochenschrift, 1896, No. 36. 



EXAMINATION. 51 

food, macroscopically visible, occur in the faeces. Nor- 
mally, however, only small particles of vegetable sub- 
stances, like potatoes, asparagus, spinach, peas, etc., are 
found, while remnants of meat can never be discovered with 
the naked eye. In case particles of meat are visible, it in- 
dicates a severe lesion of the intestinal tract. If large 
amounts of undigested food (even vegetable matter) are 
present in the faeces, it is also an indication of an existing 
severe lesion. Connective-tissue fibres appearing unal- 
tered in the faeces, according to Schmidt, 1 indicate a de- 
ficiency of gastric digestion. 

Abnormal admixtures frequently occur in the faeces, and 
are occasionally of great diagnostic importance. Thus, 
blood may be found either in its fresh condition (red) or it 
may be very dark but not coagulated. In both instances 
the blood comes from the lower portions of the large bowel. 
Sometimes the blood appears in a more changed and de- 
composed form, giving the faeces the appearance of tar. In 
this instance it originates from the higher portions of the 
bowels or from the stomach. 

An admixture of pus in the dejecta which can be macro- 
scopically recognized occurs only in instances in which pus 
exists in the lower portions of the large intestine. For if 
there is pus present in the higher portions of the bowel, it 
is usually changed before its exit in such a manner that 
it cannot be detected unless the amount is very consider- 
able. 

Fragments of tumor (polypi or torn off particles of can- 
cer) are occasionally found in the dejecta. A thorough 
examination of these may be of great help in the diagnosis. 

Mucus, although a normal constituent of the faeces, can- 
not be discovered in large amounts tinder physiological 

1 Ad. Schmidt: "Beitrage zur Diatotlierapie bei Magen- imd Darm- 
krankheiten." Munch, med. Wochensclir. , 1902. Xos. 6 and 7. 



52 DISEASES OF THE INTESTINES. 

conditions. Macroscopically visible mucus may exist in 
the following forms : (1) It may surround the fecal matter 
in the form of a glassy layer. This usually indicates a 
diseased condition of the lower portion of the bowel. (2) 
The mucus may appear in the form of membranes and may 
be evacuated either alone or after a fecal evacuation. This 
often occurs in membranous enteritis. (3) The mucus may 
appear in a mushy movement having a yellowish coloration 
and be well mixed with faeces. If a glass rod is dipped 
into such an evacuation the mucus adheres to it. (4) The 
mucus exists in small particles visible with the naked eye 
and floating in the watery dejecta. All these varieties of 
mucus with the exception of (2) indicate the presence of a 
catarrhal condition of the intestine. 

Intestinal parasites also occur in the faeces, and their 
discovery may elucidate the diagnosis. 

Chemical Examination of the Faeces. — The reaction of the 
faeces is normally neutral or slightly alkaline. Under a 
diet rich in vegetables, however, it is slightly acid. In 
cases in which there is an occlusion of the bile duct so that 
it does not empty into the intestines the reaction is strongly 
acid. The test for the reaction is best made by means of 
litmus paper. The reaction at the surface of the fecal mat- 
ter may be different from that in the interior. It is there- 
fore best to test both. 

The amount of acidity or alkalinity of the faeces can be 
determined by mixing 10 to 20 c.c. of the fresh fecal matter 
with about 100 c.c. of distilled water. A drop of a phenol- 
phthalein solution i's added and as much of a decinormal 
solution of either sodium hydrate or sulphuric acid until 
the red color appears, or if the alkalinity has to be deter- 
mined, disappears. The reaction of the faeces is, however, 
not of much diagnostic value. 



EXAMINATION. 53 

Tests for Mucin. — According to Hoppe-Seyler, mucin 
forms one of the principal constituents of the faeces. In 
order to test for it the faeces are thoroughly mixed with 
water and an equal volume of milk of lime, allowing the 
mixture to stand for several hours. It is then filtered. 
Acetic acid is now added to the filtrate. In the presence 
of mucin a precipitate forms. In case particles of sus- 
pected mucus are visible within the faeces, they can be 
examined separately in the following manner : A small flake 
of the mucus is dissolved in a weak solution of potassium 
or sodium hydrate, and acetic acid added. If the precipi- 
tate remains undissolved after the addition of the acetic 
acid in excess, it proves the presence of mucin. Inasmuch 
as nucleoalbumin also gives the reaction just described, 
the positive proof that the precipitate is due to mucin is 
afforded by heating it in a diluted mineral acid to the boil- 
ing-point. If mucin is present the heated solution will 
contain a substance reducing copper oxide. Another very 
useful test for the presence of mucin consists in staining 
the flake of fecal matter resembling mucus with a weak 
triacid solution (Ehrlich). The presence of mucus pro- 
duces a green color, while if the flake consists of albumin, 
a red color arises. This test, first described by Pariser, 1 
I have found of practical value. 

Albumin.— In order to examine the faeces for albumin, 
they are treated repeatedly with water slightly acidified 
with acetic acid. The water y extract is filtered several 
times and the filtrate examined for albumin according to 
the methods used in examinations of the urine for this 
substance. The addition of acetic acid and potassium ferro- 
cyanide, however, is best suited for this purpose. Under 
normal conditions there is no albumin present in the faeces. 
1 Pariser : Deutsche medicinische Wochenschrift, 1893, No. 41. 



54 DISEASES OF THE INTESTINES. 

Yon Jaksch * found it present in typhoid fever, in isolated 
cases of acute enteritis, and in chlorosis. 

Propeptone and Peptone. — After the test for albumin has 
been made with negative result, the watery extract of the 
faeces is treated with phosphotungstic acid, the precipi- 
tate diluted with water and sodium hydrate and a small 
amount of a weak solution of sulphate of copper added. 
A purplish-red color (biuret test) shows the presence of 
both propeptones and peptones. If it is desirable to ascer- 
tain the presence of peptones separately it is necessary to 
first precipitate the propeptone by the addition of a large 
amount of ammonium sulphate. In normal dejecta Von 
Jaksch never encountered peptone. Pathologically he 
found it in typhoid fever, dysentery, tuberculous ulcer of 
the intestine, and in perforation peritonitis. 

Carbohydrates. ~ln order to test for the presence of car- 
bohydrates, the faeces are subjected to distillation. The 
residue is extracted with alcohol and ether ; the extract is 
then boiled with water, filtered, and again boiled with the 
addition of dilute sulphuric acid. This solution is then 
subjected to Trommer's or Nylander's test for the presence 
of reducing substances. 

In order to ascertain whether starch is present the 
watery extract of the faeces is examined with Lugol's solu- 
tion, the presence of starch producing a blue color. 

If the dejecta be examined for the presence of sugar, then 
a watery extract of the fecal matter can be directly tested 
with the usual sugar reagents. Normally neither starch 
nor its derivatives (sugar) are found. 

Schmidt 2 suggested testing the watery extract of the 
fecal matter with regard to the amount of gas developing 

1 Von Jaksch : " Klinische Diagnostik. " 

2 Ad. Schmidt : Berliner klinische Wochenschrift, 1898, No. 41. 



EXAMINATION. o5 

through fermentation. For this purpose Schmidt puts the 
watery extract of the faeces into fermentation tubes (similar 
to the fermentation saccharometer) and keeps them at blood 
temperature. The greater the amount of gases developing 
in the cylindrical part of the tube, the greater the evidence 
of disturbances within the intestine. The greater propor- 
tion of the gas consists of carbonic acid and is due to its 
formation from the carbohydrates existing in the fecal 
matter. In order to be able to judge more accurately from 
this test, Schmidt examined his patients after a certain 
diet which they had been taking for several days. It con^ 
sisted of 1,560 c.c. of milk, four eggs, three zwieback, one 
plate of barley soup, one plate of flour soup, and one cup 
of bouillon a day. While Schmidt asserts that whenever & 
considerable amount of gas is found in the fermentation 
tube this indicates a real disturbance of the intestine, S. 
Basch, 1 who has made a thorough study of Schmidt's 
method in a considerable number of cases, is of the opinion 
that on the one hand a considerable amount of gas may be 
found in cases without any apparent intestinal lesion, and, 
on the other hand, grave disturbances of the intestine may 
show a total absence of gas. Inasmuch as Schmidt's fer- 
mentation method is certainly complicated and its results 
are not of great diagnostic value, I do not believe that it 
will ever come into practical use. 

Fat. — The presence of neutral fat and fatty acids is de- 
termined in the following manner : The faeces are treated 
with a considerable amount of ether; the latter is separated 
and evaporated in a water bath. The fat if present then 
remains and is visible. In order to show the presence of 

1 S. Basch : " Welche klinische Bedeutung bezeichnet die Schmidt'sche 
Gahrungsprobe der Faeces?" Zeitschrift f. klin. Med., Bd. 37, Heft 
5 and 6. 



56 DISEASES OF THE INTESTINES. 

soaps which do not dissolve in ether, another portion of 
fecal matter is first treated with acids which split up the 
soaps and then extracted with ether. The quantitative de- 
termination of the amount of fat and of its different com- 
ponents is somewhat complicated and of not much service 
clinically. Those interested in the subject may look up 
Yon Noor den's "Beitrage zur Lehre vom Stoff wechsel, " 
Heft I., p. 109, Berlin, 1892. Normally fat is never per- 
ceptible macroscopically in the faeces unless after the in- 
gestion of very large quantities. It may then be visible in 
small portions of pea size. Pathologically fat may exist 
in very large quantities in the fecal matter and give it 
a grayish silvery appearance, the so-called fatty stools. 
This frequently occurs in diseases of the pancreas, and 
also whenever the absorption by the lymphatics is greatly 
disturbed. 

Blood. — Fresh blood from the lower portion of the intes- 
tine, and also from the higher portions of the bowel if pres- 
ent in large amount, is easily recognized by its macroscopic 
appearance. Often the microscope will reveal well-pre- 
served red and white blood corpuscles. Sometimes, how- 
ever, the blood is changed to such a degree that it is not 
easily recognized. Here various tests are required in order 
to prove its existence, the same procedures being used as 
for the discovery of blood in the gastric contents. The 
haemin test which is chiefly used is made as follows : A 
small particle especially suspected of containing blood is 
dried and powdered and a portion of it put on a slide. A 
trace of sodium chloride is now added and a drop of glacial 
acetic acid poured over it and thoroughly mixed. A cover- 
glass is now put over it, the specimen is slowly heated, and 
after cooling examined with the microscope. The presence 
of hgematin crystals shows that there was blood. 



EXAMINATION. 57 

Bile Pigment. — Under normal conditions no unchanged 
bile pigment is found in the faeces. In catarrhal conditions 
of the small intestine it has been frequently detected. The 
presence of bile pigment is ascertained in the following 
manner : A particle of highly colored fecal matter is brought 
into contact with a drop of fuming nitric acid. The yellow 
color usually passes through the various colors of the spec- 
trum — red, violet to green. In some instances a green 
discoloration appears at once. The test for biliary pigment 
may also be made as follows: The faeces if liquid are 
filtered through filter paper, and if not liquid a watery 
mixture is made and filtered. When the filter paper is 
dry a few drops of nitric acid are poured on it. The colors 
just mentioned appear in the form of rings, if bile pigment 
is present. Still another test is as follows : A small quan- 
tity of the fluid dejecta is treated with a concentrated 
watery solution of sublimate. If the faeces contain biliary 
pigments in considerable quantity , the entire mixture turns 
green. If, however, the biliary pigment is adherent to cer- 
tain small fecal particles then these alone turn green. 

Biliartj Acids. — Whenever biliary pigments appear in the 
dejecta, biliary acids, as a rule, accompany them. The 
presence of biliary acids is best revealed by Pettenkofer's 
test, and is made as follows: A small quantity of fecal 
matter is thoroughly treated with alcohol, which is then 
evaporated. To the residue a weak watery solution of bi- 
carbonate of sodium is added, and to this mixture a small 
quantity of cane sugar and a few drops of sulphuric acid. 
When biliary acids are present a characteristic red or pink 
color arises. 

Urobilin. — Normally the biliary pigment within the in- 
testinal tract becomes changed into urobilin, which is the 
principal factor of the characteristic brownish color of the 



58 DISEASES OF THE INTESTINES. 

faeces. The best test for the presence of urobilin is- 
Fleischer's ] procedure which is as follows : A small quan- 
tity of faeces is put into a test tube and a small amount of 
alcohol with a few drops of hydrochloric or acetic acid 
added; the mixture is then left undisturbed for a short 
time. The presence of urobilin produces a yellow or 
brown color, the latter, if present in large amount. If 
the alcohol is now poured out and a few drops of sodium 
hydrate added, as well as a small quantity of a chloride-of- 
zinc solution, there appears, according to the amount of 
urobilin, a more or less greenish fluorescence in direct rays 
of light, while in transmitted light the fluid appears pink 
or yellowish-red. If the watery extract of faeces to which 
some ammonia has been added is filtered and chloride of 
zinc added, the presence of urobilin produces a pinkish-red 
precipitate. If this precipitate is filtered under addition 
of alcohol containing some ammonia there appears a more 
or less greenish fluorescence (Schmidt's 2 test). A small 
piece of fecal matter is treated with a concentrated watery 
solution of sublimate and thoroughly mixed with a glass 
rod. The presence of urobilin gives rise either imme- 
diately or a little later to a pinkish-red color, while biliver- 
din, if present, produces a greenish color. 

Normally urobilin is present in the faeces. Its absence 
is observed only in pathological conditions. 

Acholic Stool. — The acholic stool presents a grayish- 
white, ashy gray, or clay color. It is usually of a soft salve- 
like consistency. It occurs (1) in conditions in which 
there is a total absence of bile in the intestine, and (2) 
whenever the absorption of fat is greatly impaired. Until 
very recently the grayish- white color has been generally 

1 R. Fleischer : "Krankheiten des Darms, "p. 1160, Wiesbaden, 1896. 

2 A. Schmidt : Verhandlungen des Congresses f . Innere Med. , 1895. 



EXAMINATION. 59 

ascribed to the absence of biliary pigments and their modi- 
fications (urobilin) , but Fleischer and Bunge J have conclu- 
sively shown that the whitish color may be observed in 
faeces containing urobilin, the color being due to the pres- 
ence of large amounts of fat. In the latter instance the 
stool, after being treated with large amounts of ether, thus 
separating the contained fat, assumes a brownish color. 
This I can confirm also from my own experience. 

Ferments. — In order to ascertain the existence of fer- 
ments in the faeces a glycerin extract of them may be made 
or the fecal matter may be directly mixed with water con- 
taining a small proportion of thymol, and filtered. The 
filtrate, or the glycerin extract, can now be directly tested 
for the presence or absence of the different ferments, tryp- 
sin and diastase. In order to test for trypsin the fecal 
filtrate is made alkaline by the addition of bicarbonate of 
sodium and a few flakes of fibrin are added. The solution 
is kept at blood temperature for a few hours and then tested 
with potassium hydrate and a weak solution of sulphate of 
copper. If trypsin is present, a pinkish-red color will 
arise in consequence of the peptone which has formed 
(biuret test). In order to test for diastase, a few cubic 
centimetres of the filtrate are mixed with about half the 
amount of a starch solution and kept at blood temperature 
for half an hour. The mixture is now subjected to Fehling's 
or Trommer's test for the presence of sugar. Normally, as 
a rule, these ferments are absent, but in pathological condi- 
tions, especially in diarrhoea, they are frequently found. 

Concretions. — The faeces occasionally contain concretions 
which may be of diagnostic importance. In order to de- 
tect them, especially if they are small, the faeces must be 

1 Bunge : " Lehrbuch der phys. u. pathol. Chemie, " Leipsic, 1887, 
p. 192. 



60 DISEASES OF THE INTESTINES. 

thoroughly mixed with warm water and poured through a 
large sieve. While the fecal matter is on the sieve some 
more water is added and the mass constantly stirred with 
a wooden stick. Any concretions present will thus be dis- 
covered remaining on the surface of the sieve. 

Recently Boas and I have each constructed special stool 
sieves for the same purpose. Boas' 1 apparatus consists 
of two hemispheres, one fitting into the other, the lower of 
which forms the sieve. In the upper hemisphere are two 
openings, a larger one to admit water and a smaller one 
through which a glass rod for stirring the faeces may be 
introduced. Boas has enhanced the value of this appara- 
tus by using it in the examination of the faeces not only 
for gall stones, but also for undigested food remnants. 
Boas expresses himself as follows: "The apparatus serves 
the purpose of easily isolating substances that are indi- 
gestible or that have escaped digestion by the stomach or 
bowel, and of rendering them in this way more easily 
accessible to a gross and microscopical examination. It 
also serves the purpose of viewing in their whole extent 
pathological admixtures to the stool, such as mucous con- 
crements, and entozoa and of examining them in all di- 
rections. The whole procedure lasts from ten to twenty 
minutes." 

Every physician who has at heart the examination of 
the bowel function will receive with interest this new ap- 
paratus of Boas. The constant stirring of the faeces with a 
glass rod seems to be somewhat tiresome. 1 2 have, there- 
fore, devised another apparatus which I have used for 

1 J. Boas: "Em Stuhlsieb." Deutsche medicinische Wochenschrift, 
1900, No. 36, p. 583. 

2 M. Einhora: "A New Stool Sieve." N. Y. Med. Journal, August 
24th, 1901, p. 378. 



EXAMINATION. 



61 



some time for the same purposes as Boas, and which 
seems to me to have some advantages over Boas' stool 
sieve. The apparatus (Fig. 16) is composed of three 
parts: 1. A flour sieve (Fig. 16, B). 2. A cover (Fig. 
16, A) provided with a large opening (Fig. 16, C). 3. A 
tripod (Fig. 16, D). The flour sieve, which is the princi- 




FlG. 16. 



Fig. 17. 



Fig. 16.— Dr. Einhora's Stool Sieve, ^i. Cover; B, flour sieve; C, large opening; D, 

tripod ; E. handle. 
Fig. 17.— Dr. Einhorn's Stool Sieve : Section. F. Stirring apparatus ; G. hemisphere of 

wire netting. 



pal part of the apparatus and which may be used for the 
examination of faeces without further additions, consists 
of a cylindrical vessel the bottom of which is formed by a 
hemisphere of fine wire gauze (Fig. IT, G) . In this cyl- 
inder is an appliance for stirring (Fig. 17, F), consisting 
of two circular wires placed at right angles and one 
straight horizontal wire which, perforating the cylinder, 
ends outside of it in the handle (E). By turning this 
handle the stirring apparatus is put in motion, and, 
the wires running close over the wire sieve, the fseces 
are constantly brought in contact with the latter. In 



62 DISEASES OF THE INTESTINES. 

the presence of water a constant washing and separa- 
tion into fine particles of the brittle faeces takes place. 
These finely separated substances flow off with the 
water through the sieve, whereas coarser particles remain 
behind. 

Method of Examination. — The faeces to be examined 
are put into the cylinder (B), the cover (J.) is put on, and 
the apparatus is placed upon the tripod (D) . The appara- 
tus being placed under a water faucet, the water is allowed 
to run directly into the opening (C) of the cover. At the 
same time the handle (E) is constantly turned. The 
whole process is usually terminated in from three to six 
minutes. We now notice that the water runs off clear. 
We then take off the cover and inspect the residue on the 
wire gauze. In a normal stool the remnants are very 
small, as I have determined by several examinations. They 
consist of small pieces of cellulose, connective-tissue shreds, 
and some fruit pits, the total quantity usually not exceed- 
ing half a tablespoonful. In pathological cases the residue 
is at times increased. With this method of examination 
undigested substances and concrements are very easily 
found. 

Method of Ascertaining the Motor Function of the 
Intestine. — By means of the stool sieve it is easy to dis- 
cover any foreign, indigestible matter passing through the 
alimentary tract. This can be utilized for the determina- 
tion of the motor function of the digestive tract. The 
test is made as follows : Patient is given from three to five 
small porcelain pills in a capsule after breakfast. There- 
after the fecal passages are examined separately on the 
stool sieve and the time is noted when all the porcelain 
globules have been recovered on the sieve. The longer the 
time required for this purpose the slower the motor func- 



EXAMINATION. 63 

tion of the intestine, and vice versa. Normally it takes 
from twenty-four to forty-eight hours for the expulsion of 
all the porcelain globules through the rectum. 

The following different concretions may be met with in 
the faeces: (1) Gallstones; (2) pancreatic calculi; (3) en- 
teroliths; (4) coproliths; (5) foreign bodies. 

Biliary calculi are easily recognized when they attain 
considerable size. When they are very small, however, 
their recognition is somewhat more difficult. The princi- 
pal constituents of biliary calculi are cholesterin and bile 
pigment in conjunction with lime. 

The small concretions (sand) suspected to be of biliary 
origin should be examined in the following way : About 
2 gm. of the mass is well powdered and treated with 20 
c.c. of ether, thoroughly mixed and filtered, the filtrate 
evaporated and tested for the presence of cholesterin in the 
following manner : (a) Part of the residue is dissolved in 
hot alcohol and put aside on a porcelain dish for spontane- 
ous evaporation. The precipitate is examined under the 
microscope. Crystals of rhomboid shape with a ragged 
edge are characteristic of cholesterin. (b) Another por- 
tion of the residue is directly put on a slide, a drop of 
concentrated sulphuric acid added, and covered with a 
cover-glass. The cholesterin crystals assume a carmine 
color- at their margins. If now a drop of Lugol's solution 
is added a violet color arises, (c) Another portion of the 
residue is treated with hydrochloric acid and a trace of 
chloride of iron and evaporated. If cholesterin is present 
a blue color arises. The residue of the original ether mix- 
ture is treated with diluted hydrochloric acid, heated, and 
extracted with chloroform after it has cooled off. The 
chloroform extract is now tested with Gmelin's reaction 



$± DISEASES OF THE INTESTINES. 

(fuming nitric acid). The presence of bile pigment pro- 
duces the well-known change of colors. 

Pancreatic Calculi. — Pancreatic calculi usually have a 
rough surface, are brittle, and may be faceted. They are 
soluble in chloroform and produce on evaporation an aro- 
matic odor (Minich 1 )- Bile pigment and cholesterin are 
absent. 

Enteroliths or calculi formed in the small intestine usu- 
ally consist principally of inorganic salts (lime, magnesia). 
They are light in color and ordinarily of small size. They 
occasionally form after an extensive use of mineral medica- 
ments (lime, magnesia, etc.). They hardly ever give rise 
to intestinal obstruction. 

Coproliths or fecal calculi are found in the large bowel, 
principally in places in which there is a retardation in the 
passage of the faeces. Thus they are encountered in the 
caecum, in the appendix, in sacculations of the colon, and 
in the rectum. The coproliths are of stony hardness and 
of sausage shape. They usually show on section concen- 
tric rings. Occasionally they attain considerable size and 
may give rise to obstruction of the bowel. 

Foreign Bodies. — Foreign bodies which have been swal- 
lowed may pass through the entire intestinal tract and be 
eliminated in the faeces. Thus pieces of bone, coins, mar- 
bles, needles, and all kinds of foreign substances may be 
found in the stools. In rare instances concretions of shellac 
are discovered in the stools of patients who have drunk 
furniture polish, the shellac forming concretions after the 
absorption of the alcohol. Hair balls may be found in 
patients who habitually bite off and swallow hair. 
1 Minich : Berliner klin. Wochenschrift, 1894, No. 8. 



EXAMINATION. 



65 



Microscopical Examination. 

The microscopical examination of the f seces is occasionally 
of assistance in establishing the diagnosis. With Ewald * 
I do not think it necessary to examine microscopically the 
faeces of every patient presenting intestinal symptoms. In 




Fig. 18.— Normal Faeces, showing a few Fat Crystals and Fat Globules ; Digested Muscle 
and Epithelial Cells ; Micro-organisms. 

cases, however, in which the diagnosis is not quite clear 
and the symptoms point to an intestinal lesion, a micro- 
scopical examination of the faeces should be made. 
Diarrhceal stools may be examined under the microscope 

1 C. A. Ewald: "Diseases of the Intestines." Twentieth Century- 
Practice of Medicine, vol. ix., p. 113. 
5 



66 DISEASES OF THE INTESTINES. 

without any further preparation. Solid fecal matter is 
examined by taking a small particle of the f seces, putting it 
on a slide, and mixing it thoroughly with a drop of physi- 
ological salt solution. In order to avoid the unpleasant 
odor, a small amount of a watery one-per-cent formalin 
solution may be first added to the fecal matter. The micro- 




Fig. 19.— Normal Faeces showing Detritus, Plant Cells, Digested Muscle Fibres, Bacteria. 

scopic picture of the normal faeces varies greatly according 
to the diet. In people living on a meat diet no vegetable 
residue will be seen, while there will be no remnants of 
meat in people subsisting on- an exclusively vegetable diet. 
In case of a mixed diet there will be remnants of both in 
the stool. A mixed diet will reveal the following appear- 



EXAMINATION. 67 

ances: There will be a large number of plant cells, the 
remnants of various vegetables and fruits. They are usu- 
ally of considerable size, present peculiar shapes, and can 
be easily differentiated from animal cells (Figs. 18, 19, 20, 
21). The peels of pears and apples and of prunes com- 
monly pass out in the stool entirely unchanged. Notwith- 




Fig. 20.— Different Varieties of Vegetable Cells found in Normal Faeces. 

standing the presence of these plant cells in the stools 
starch, as a rule, is absent. Thus the microscopical speci- 
men when stained with Lugol's solution will show no blue 
color. If, however, starch appears in a stool in well-pre- 
served granules, it is always pathological, indicating de- 
ficient digestion. Minute fragments of meat are found 



68 DISEASES OF THE INTESTINES. 

in small quantity in the stools. Although considerably 
changed the muscles can be recognized as such, and the 
transverse markings can often be noticed. Frequently they 
present a yellowish tinge from biliary pigment. Connec- 
tive-tissue fibres and also elastic fibres are occasionally met 




Fig. 21.— Stool of an Hysterical Patient who Simulated Passing of Large Quantities of 
Mucous Membranes in the Faeces. The membranes under the microscope showed the 
structure of common tissue paper ; a few plant cells, epithelial cells, and fat crystals 
were also present. 

with, both being quite resistant to the action of the diges- 
tive juices. The presence of numerous pieces of meat in 
the stool is pathological. 

Fat — Microscopically fat can be detected in the faeces in 
the form of colorless small globules which may exist in 



EXAMINATION. 69 

large numbers after an excessive milk diet or in the shape 
of small needle-shaped crystals, or again in the form of 
sheaves. The small crystals of needle shape usually occur 
singly, and consist mostly of fatty acids, while the sheaves 
consist of fatty soaps. The fatty-acid crystals melt and 
disappear when heated, while the soaps remain unchanged. 
Ether likewise causes a disappearance of the fatty acids, 
while the soaps remain unchanged. Kieder ' suggests the 
use of the dye stuff Sudan II. (C 2a H 10 NjO) in a concentrated 
alcoholic solution for the differentiation of the fats. This 
dye stains plain fat bright red, while crystals of fatty acid 
and of lime and magnesia soaps remain unchanged. While 
normally these different forms of fat appear in very scanty 
amounts in the faeces, they may be found considerably in- 
creased under pathological conditions (affections of the 
liver, pancreas, and acute enteritis). 

Crystals.— Besides the crystals of fatty acids and their 
soaps the following crystals are met with in the faeces: 
oxalate of lime appears in the well-known envelope form of 
varying size, especially after a diet consisting principally 
of vegetables. Calcium carbonate occasionally occurs in the 
form of amorphous granules or dumbbell-shaped crystals. 
Neutral phosphate of calcium and ammonio-magnesium 
phosphate crystals are often present and can be readily rec- 
ognized, the former occurring in more or less well-defined 
wedge-shaped crystals collected into rosettes, the latter pre- 
senting the well-known coffin shape. They are soluble in 
acetic acid. All the crystals just mentioned are found in 
normal as well as in pathological faeces, and have no diag- 
nostic importance. Bismuth crystals: when bismuth is 
internally administered it is usually found in the faeces in 

1 Rieder : Deutsches Archiv fur klin. Med., 1898, Bd. 59, Heft 3 and 
4, p. 444. 



70 DISEASES OF THE INTESTINES. 

rhomboid crystals of a dark-brown or almost black color 
(Fig. 22). Hsematoidin crystals are occasionally encoun- 
tered in severe catarrhal conditions of the intestines or 
shortly after intestinal hemorrhages have taken place. 
They occur in small amorphous particles of an orange or 




Fig. 22.— Specimen of Stool of Mrs. W., living on Milk Diet and taking Bismuth and 
Magnesia. Bismuth and magnesia crystals, some fat globules and detritus. No muscle 
or plant cells. 

ruby red color, or in crystals of the rhombic system. 
Charcot-Leyden crystals of spermin phosphate, having 
the shape of grains of oats, are occasionally met with in 
the faeces and are of diagnostic importance. According to 
Leichtenstern, ] these crystals are very frequently found in 
1 Leichtenstern : Deutsche med. Wochenschrift, 1892, No. 25. 



EXAMINATION. 



71 



the fasces whenever intestinal parasites (helminthiasis) 
exist. These crystals, however, occur also in other patho- 
logical conditions as in typhoid fever, dysentery, tubercu- 
losis of the lungs. In rare instances the Charcot-Leyden 
crystals are absent in cases of helminthiasis. When they 




Fig. 23.— Specimen of Stool of Mrs. V., with Chronic Intestinal Catarrh. Groups of epi- 
thelial cells ; detritus ; a few muscle cells, partly digested ; plant cells; bacteria; yeast 
cells. 

occur, however, they are an indication that the stools 
should be carefully watched for the presence of intestinal 
worms. 

Elements Derived from the Intestinal Wall. — Epithelial 
cells and also goblet cells occur occasionally in the faaces, 
but only in scanty number (Fig. 23). They are very sel- 



72 DISEASES OF THE INTESTINES. 

dom unchanged with a distinctly visible nucleus ; usually 
they appear in a metamorphosed condition without any 
perceptible nucleus. Larger accumulations of epithelial 
cells may be found in desquamative catarrhal conditions 
of the intestines. 




Fig. 24,— Stool of Patient L. , with Acute Dysentery. Pus cells in considerable number; 
occasional epithelia ; mucus ; detritus. 



Blood. — Blood in the fa3ces is occasionally easily recog- 
nized under the microscope, both red and white blood cor- 
puscles being present. This, however, is the fact only in 
hemorrhages of the lower portion of the rectum. In hem- 
orrhages originating in the upper portion of the large 
bowel or in the small intestine, the blood cells are usually 



EXAMINATION. 



73 



already greatly changed and not to be recognized as such 
microscopically . 

Pus. —Pus corpuscles in the dejecta occur in ulcerative 
processes of the intestines or whenever an abscess has 
discharged its contents into the bowel. Besides these 
two conditions, it is also met with in dysentery. The pus 




Fig. 25.— Stool of Patient H., with Chronic Dysentery, during an Acute Exacerbation. 
Highly magnified. Amoebae ; red and white blood cells ; crystals of fat and ammonio- 
magnesium phosphate ; plant and muscles cells ; detritus. 

corpuscles are then distinctly visible under the microscope 
(Figs. 24, 25, 26). [For the beautiful execution of the above 
drawings I am indebted to Dr. C. A. Elsberg of this city.] 
Mucus. — Mucus is frequently seen in the dejecta under 
the microscope. It is recognized by its thread-like ap- 



74 



DISEASES OF THE INTESTINES. 



pearance (Fig. 27). Occasionally it is also amorphous. 
Thionin colors mucus reddish-violet, while it stains other 
proteid substances blue. Mucus is often present in ca- 
tarrhal conditions of the intestine and also in membranous 
enteritis. 
Pieces of Tumors. — In rare instances a small fragment of 




Fig. 36.— From the Same Patient, a Few Days Later. Highly magnified. Amoebae ; fat 
in globules and crystals ; a lew red and white blood corpuscles ; muscles ceils ; detri- 
tus ; bacteria. 

tumor may be found in the dejecta. Under the microscope 
the structure of the mass will be seen and its character de- 
termined. The result of such an examination may be of 
great diagnostic importance. 

Micro-organisms. — Numerous micro-organisms are found 



EXAMINATION. 75 

in the faeces normally as well as pathologically. Their 
number averages in daily evacuations fifty -three milliards. 
Sometimes they may reach as high a figure as four hundred 
milliards. Beginning with the stomach the number of 
micro-organisms steadily increases all through the intesti- 
nal tract down to the large bowel, where the maximum is 




Fig. 27.— Specimen of the Stool of Mrs. J. B., Suffering from Intestinal Catarrh. Mucus 
all over the field of vision ; a few plant cells and muscle cells, and an occasional fat 
crystal. 

reached. The micro-organisms appear to be intimately 

connected with the physiological processes of digestion. 

This is true notwithstanding the valuable investigations of 

Nencki, Macfadyen, and Sieber, 1 and Thierf elder and Nut- 

*!Neiicki, Macfadyen, und Sieber: Archiv f. experimentelle Patho- 
logie u. Pharmakologie, Bd. 28, S. 301. 



76 DISEASES OF THE INTESTINES. 

tal, 1 which have shown that normal digestion is possible 
even without bacteria. Pathologically various kinds of 
bacteria play a very important part. Besides certain spe- 
cies of pathogenic bacteria, the micro-organisms normally 
sojourning in the intestine occasionally assume morbific 
properties. 

The different varieties of micro-organisms in the intes- 
tinal tract have been thoroughly studied by Mannaberg, 2 
who found fourteen different species of bacilli, nine species 
of micrococci, and four species of schizomycetes. Of the 
latter saccharomyces cerevisiae are most frequently encoun- 
tered in the faeces. They are found in groups forming 
three or four buds, and assume a mahogany color when 
treated with Lugol's solution. Of the bacteria and cocci 
the following deserve special mention : 

The bacterium coli commune, first described by Esche- 
rich, 3 occurs in the form of thin or thick rods being about 
0.4 v. in length. Some show motile power. They are well 
stained by the ordinary anilin dyes and decolorized by 
Gram's solution. Their colonies growing upon gelatin re- 
semble those of the bacillus of typhoid fever. 

The bacterium lactis aerogenes (Escherich) greatly re- 
sembles the bacterium coli commune. It is frequently 
found in the stools of infants, and is now and then met with 
in those of adults. It is found in thick rods frequently 
lying in pairs. They are non-motile and have the property 
of causing fermentation of milk, producing coagulation and 
formation of gas within sixty hours. 

1 Thierfelder u. Nuttal ; Zeitschrift f. phys. Chemie, Bd. 21, S. 109, 
u. Bd. 22, S. 62. 

2 Mannaberg : " Die Bacterien des Darms "— Nothnagel's Erkrankun- 
gen des Darms, Wien, 1895. 

3 Escherich : "Beitrage zur Kenntniss der Darmbacterien. " Munch- 
ener med. Wochenschr. , 1886, No. i., 43-45. 



TREATMENT. 77 

Bacillus putrificus coli (Bienstock 1 ) forms slender rods 
3 fi in length. This bacillus energetically decomposes 
proteid substances in presence of air under the formation 
of ammonia, amin bases, fatty acids, tyrosin, phenol, indol. 

While all the above-mentioned micro-organisms give a 
mahogany or brown color with solutions of iodine, there 
are a few varieties which give a blue color with this sub- 
stance. To the latter belongs the bacillus butyricus de- 
scribed by Nothnagel. 2 It is rod-shaped, 3 to 10 p. long 
and 1 ii thick. It is often lemon-shaped. This bacillus 
is anaerobic and produces fermentation of starch, sugar, 
and cellulose, forming butyric acid and gas. The bacillus 
butyricus is often found in pathological conditions of the 
intestine, but occurs in small numbers also in normal faeces. 

Of the pathogenic micro-organisms, cholera, typhoid, and 
tubercle bacilli are found in the faeces. The cholera and 
typhoid bacilli causing infectious diseases do not belong, 
strictly speaking, to the micro-organisms producing dis- 
eases of the intestine alone. The tubercle bacilli, occasion- 
ally producing intestinal tuberculosis, are recognized in the 
faeces by the same methods which are employed in the 
examination of the sputum. 

TREATMENT. 

Diet. 

The principles of diet are fully described in my book on 

the stomach. Here I will add a few remarks referring to 

the dietetic treatment of intestinal diseases. As in the 

case of the stomach, acute intestinal disorders lasting a 

1 B. Bienstock : "Ueber die Bacterien der Faeces. " Zeitschr. f. klin. 
Med., Bd. 8, 1884. 

5 H. Nothnagel : "Die normal in dera Menschendarm vorkommenden 
niedersten (pflanzlichen) Organismen." Zeitschr. f. klin. Med., Bd. 3, 
1881. 



78 DISEASES OF THE INTESTINES. 

few days or weeks must be managed according to the prin- 
ciple of rest. Very scanty and light foods (mostly liquid) 
should be given. In chronic ailments of the intestines the 
principle of rest may also be utilized occasionally for a 
short time, while as a general rule we should bear in mind 
the necessity of introducing sufficient quantities of food 
and gradually accustoming the intestinal tract to the ordi- 
nary foods. 

In some instances it is possible to exert a wholesome 
influence upon the disturbances of the intestine by appro- 
priate dietetic measures. This applies especially to dis- 
orders accompanied by constipation or by diarrhoea. 

I. Articles of diet which increase the intestinal peristalsis 
or " laxative foods " are the following : Most fruits, both 
raw and cooked, and fruit juices increase the peristalsis 
in consequence of the organic acids which they contain, as 
apples, pears, plums, peaches, strawberries, gooseberries, 
dates, and figs. Most salads and garden vegetables also 
increase peristalsis, firstly, owing to the large amount of 
water they contain, and secondly, owing to the consider- 
able residue which is left undigested, as, for instance, 
melons, cucumbers, tomatoes, pumpkins, all kinds of cab- 
bage. By many of the latter foods the peristaltic action 
of the intestine is also increased on account of the forma- 
tion of acid and gaseous products. Fresh beer, cider, 
bonny-clabber, and kumyss act in a similar manner. Cold 
drinks of plain water or carbonated water act as mild ape- 
rients in some instances. Here a reflex action upon in- 
testinal peristalsis due to irritation must be assumed, for 
often a movement of the bowels follows very soon (a quar- 
ter of an hour to one hour) after drinking. 

II. Articles of diet which diminish the intestinal peri- 
stalsis or "constipating foods": (1) All substances con- 



TREATMENT. 79 

taining a considerable portion of astringent agents, par- 
ticularly tannic acid, as, for instance, dried bilberries, 
French red wines (particularly San Eafael wines), tea, ca- 
cao, the acorn preparations like acorn coffee, acorn cacao. 
(2) Foods which have a mucilaginous character and thus 
somewhat allay irritation also have a slightly constipating 
effect : sago, tapioca, barley, rice. (3) Foods which leave 
no residue whatever or very little residue, and thus exert 
no irritation. To these belong egg water (prepared by dis- 
solving the white of an egg in some water), scrajjed raw 
meat, mutton broth. 

Some foods manifest different action in different individ- 
uals. Thus, for instance, milk is constipating in one per- 
son and laxative in another, while in still others it has no 
special effect upon intestinal peristalsis. 

Most foods have no marked influence upon the intestinal 
peristalsis. To these belong most kinds of meat and fish 
not too highly seasoned, the various meat powders, and 
most artificial foods like meat peptone and nutrose, eucasin, 
somatose, sanose, eggs prepared in different ways, well- 
baked bread, wheaten or rye bread, crackers, . zwieback, 
fats in small amounts, especially butter. The preparation 
of the foods has an important bearing with regard to its 
action upon the intestinal peristalsis. The finer the foods 
are the less irritating they will act, and the coarser the 
particles the greater the irritation they produce upon the 
intestinal muscular layer. Highly seasoned foods also act 
as a stimulant of the peristalsis. 

In some severe conditions of the intestines the ordinary 
way of ingestion of food must be avoided for a short period. 
Here artificial feeding is employed. Artificial feeding can 
be done in two different ways: rectal alimentation and 
subcutaneous alimentation. 



80 DISEASES OF THE INTESTINES. I 

1. Rectal Alimentation. — The rectum and the greater 
part of the large bowel should be emptied if possible be- 
fore injecting the feeding enema. The latter is best accom- 
plished by using a fountain syringe and a soft- rubber tube 
which is introduced for about Rye to seven inches into the 
rectum. The quantity of the feeding enema may be be- 
tween five and ten ounces. As feeding enemas the follow- 
ing substances are used : (a) The different kinds of pep- 
tones and propeptones in the market of which about two 
to three ounces can be dissolved in six to eight ounces of 
water. The different beef juices may also be dissolved in 
water and injected in corresponding quantities, (b) The 
milk and egg enemas. These are mostly used. Their 
composition is as follows : Six to seven ounces of milk, 
one or two raw eggs well beaten up, one teaspoonful of 
powdered sugar, and the point of a knifeful of salt. The 
addition of pancreatin (one tube of Fairchild pancreatin 
to one enema) will facilitate assimilation, (c) Meat-pan- 
creas enema. Leube ' employs enemas consisting of well- 
chopped meat mixed with fresh pancreas. 

Besides these food enemas injections of water into the 
bowel are made in order to increase the amount of fluid in 
the system. These injections of water for the purpose of ab- 
sorption are of great importance. Usually saline solutions 
are employed in quantities varying from one pint to one 
quart. The nutritive enema should be given three or four 
times in twenty -four hours, and the water enemas for ab- 
sorption once or twice a day. 

2. Subcutaneous Alimentation. — In diseases of the intes- 
tine special conditions are met with in which neither the 
ordinary way of feeding nor rectal alimentation is possible. 

'Leube: Leyden's "Handbuch der ErDahrungstherapie, " Bd. i., p. 
508, Leipsic, 1897. 



TREATMENT. 81 

Here an attempt must be made to introduce nourishment 
subcutaneously. Most food substances cannot be intro- 
duced under the skin without inflicting more or less injury. 
Two substances only form an exception and are of practical 
value : (a) Olive oil. This can be injected subcutaneously 
to the amount of one ounce twice or three times a day. It 
is hardly necessary to say that the oil as well as the syringe 
used for this purpose should be thoroughly sterilized. A 
large-sized Pravaz syringe is employed, and but little 
pressure exerted while injecting. This precaution is neces- 
sary in order to obviate any traumatism (tearing) of the tis- 
sues. The best place for the injection is the thigh, (b) 
Water. A saline solution is subcutaneously injected in 
amounts varying from one pint to a quart. This serves to 
increase the amount of fluid in the system. The injection 
is made by means of the fountain syringe to the end of 
which an aspirating needle is attached. The same pre- 
cautions as above are necessary. The saline injection 
may be employed twice or three times a day if necessary. 

Mechanical Procedures. 

Injections. — Injections into the bowel in the form of clys- 
ters were used for curative purposes even in old times. 
The regular syringe with its stiff end may, if forcibly in- 
serted, give rise to damage of the rectum. For this reason 
nowadays a soft-rubber rectal tube is employed, to which 
a fountain or Davidson syringe or any form of syringe can 
be attached. The tube being flexible cannot injure the in- 
testinal walls. It can also be introduced higher up than 
the ordinary hard-rubber end pieces of the fountain syringe. 
Instead of the fountain syringe a funnel apparatus similar 
*o the one used in gastric lavage may be employed. For 
Washing out the bowel Leube-Rosenthal's appliance for 



82 DISEASES OF THE INTESTINES. 

washing out the stomach can be used to advantage. For 
irrigation of the bowel Kemp's hard-rubber rectal double- 
current irrigator can be conveniently employed (Fig. 28). 

These injections into the bowel are made for various 
purposes : 

1. To produce an evacuation. About a quart of luke- 
warm water to which a teaspoonful of salt is added can 
be employed, or a piece of soap dissolved in the same 




G. TIEMANN & CO., N. Y, 



Fig. 28.— Dr. R. C.Kemp's Rectal Irrigator (New Model). Outer tube of hard-rubber; 
central tube of metal. Hard-rubber flange, protecting sphincter from transmission of 
heat through the metal parts. 

amount of water. As a rule, it is not advisable to intro- 
duce larger quantities of water than these as they distend 
the bowel too much. In greatly atonic conditions, how- 
ever, in which a quart of water may be inefficient, an 
injection of from two to three quarts will be required. In- 
jections of oil (olive oil or sesame oil) in quantities varying 
from half a pint to one pint have been recommended by 
Fleiner.' According to this writer the oil should be in- 
jected at blood temperature into tho rectum when retiring 
and be retained over night. While olive oil was used as a 
laxative injection long ago by Habershon ' and others, we 
owe its methodical use to Fleiner, to whom is also due the 
credit for having promulgated the method. Small injec- 
tions of glycerin (one or two drachms) in about an ounce 

Kleiner: "Ueber die Behandlung der Constipation." Berl. klin. 
Wochenschr. , 1893, Nos. 3 and 4. 
3 Habershon : "Diseases of the Abdomen, " London, 1862. 



TREATMENT. 83 

of water can also be advantageously employed for produc- 
ing an evacuation of the bowels. 

2. Injections may be resorted to either to strengthen 
the tonicity of the bowel, in which case plain very cold 
water in amounts of from one to two quarts can be em- 
ployed, or for medicinal purposes, i.e., for applying cer- 
tain medicaments directly to the intestinal mucosa. The 
drugs most frequently used for this purpose are nitrate of 
silver, tannic acid, subnitrate of bismuth, as astringents; 
thymol, hydrogen peroxide, boracic acid, essence of pep- 
permint, as disinfectants. 

Massage and Gymnastic Exercises. — Massage is frequently 
employed in functional diseases of the intestine. Its field 
of usefulness lies principally in neurotic and atonic condi- 
tions. Massage should be applied by well-trained and 
experienced persons. Abdominal massage requires great 
care, as too rough manipulation is liable to do great harm. 
Gymnastic exercises and sports are well adapted to stimu- 
late and strengthen the muscles of the abdomen as well as 
those of the intestine. Ewald particularly recommends 
rowing in boats with sliding seats as an exercise which 
gives definite results in chronic intestinal torpidity. Golf, 
billiards, horseback riding, bicycle riding, walking may 
also be included among the exercises contributing to a ton- 
ing up of the system. 

Hydrotherapy. — Moist applications in the form of either 
Priessnitz's compresses or poultices are often of benefit. 
Priessnitz's compresses are stimulating, while the warm 
fomentations serve as a sedative. The latter are applied 
to allay pain, the heat producing a temporary paralysis of 
the superficial sensory nerves. Instead of either cold or 
warm compresses a rubber bag filled with either cold or 
hot water may be applied. When warm applications are 



84 



DISEASES OF THE INTESTINES. 



required they can also be used in the form of the Japanese 
box. Sitz baths of various temperatures may be employed. 
A shower bath, especially over the abdomen, of cold or 
warm water or of alternating cold and warm water, is also 
of benefit. Many of these procedures may be combined 

with massage, and in this 
way the curative action 
is enhanced. 

Elect ic ity . — The f ara- 
dic, galvanic, or frank- 
linic currents are em- 
ployed. All these three 
can be used percuta- 
neously; the first two 
also intrarectally. The 
faradic current is mostly 
applied in atonic condi- 
tions of the bowel with 
the object of stimulating 
the motor function of the 
intestines. The galvanic 
current i s principally 
employed in painful intestinal affections of neurotic char- 
acter. The franklinic or static current may be advan- 
tageously used in both conditions. For the intrarectal 
application of the current I use an electrode which in prin- 
ciple is very similar to that of Boudet * and consists of a 
perforated hard-rubber end piece in which is lodged a 
metallic button connected by means of a wire with the bat- 
tery. To the upper end of the hard-rubber piece is at- 
tached a soft-rubber tube leading to an irrigator and pro- 

1 Boudet : Cited after A. Mathieu : " Treatment of Diseases of the 
Stomach and Intestines, " New York, 1894, p. 171. 




Fig. 29.— Rectal Electrode. 



TREATMENT. »o 

vided with a stopcock (see Fig. 29). Proceed as follows: 
The irrigator is filled with water at blood temperature. 
The hard-rubber piece, or the rectal electrode, is smeared 
with vaseline and introduced into the rectum. Another 
plate electrode is moistened and placed over the abdomen, 
the stopcock partly opened, and the current applied. The 
water running from the end piece of the electrode into the 
bowel carries the electricity along with it. The electrical 
application should last from five to ten minutes, the 
amount of water used varies from ten to fifteen ounces. 
The outflow of the water can be regulated by the stopcock 
arrangement. I have applied both the faradic and gal- 
vanic currents with this apparatus and found it very con- 
venient. The faradic current may be applied as strong as 
the patient can bear, while the galvanic current should be 
used with the negative pole in the rectum, the intensity 
of current ranging from eight to fifteen milliamperes. 



CHAPTER III. 

ACUTE AND CHEONIC INTESTINAL CATAEKH. 

ACUTE INTESTINAL CATARRH. 

Synonyms : Enteritis acuta ; Catarrhus intestinalis acu- 
tus; Acute diarrhoea; Cholera nostras. 

Definition. — An inflammatory affection of the intestines 
characterized by a sudden development of pains and more 
or less loose movements. 

Etiology. — Acute intestinal catarrh is one of the most 
frequent diseases. While it occurs more often in infants 
and children it is found in persons of all ages. 

The affection may attack the entire intestinal tract or 
may be limited to a part of it. Thus we may have a duo- 
denitis, jejunitis, ileitis, typhlitis, colitis, and proctitis 
(inflammation of the rectum) . With regard to frequency 
the colon is most often affected. According to Woodward, l 
an inflammation of the small intestine alone hardly ever 
exists, a portion of the large bowel always being affected. 
Intestinal catarrh is either primary (idiopathic) or second- 
ary when occurring as a sequel of other diseases. Acute 
enteritis may be due to a number of causes : 

1. It may result from the ingestion of heavy indigestible 
food, ice-cold drinks, and tainted meat or fish, unripe fruit, 
stale or sour beer, bad water. 

2. Good food and drink taken in unusually large quanti- 
ties may also produce this condition. 

1 Woodward : " The Medical and Surgical History of the War of the 
Rebellion, " vol. 1 , part 2. 



ACUTE INTESTINAL CATARRH. 87 

3. A host of organic and inorganic substances may chem- 
ically irritate the intestinal mucosa and cause inflammation. 
All the drastic remedies, like croton oil, colocynth, jalapj 
etc., belong to these organic irritating substances; of the 
inorganic may be mentioned tartar emetic, arsenic, lead, 
sulphate of copper, all the mercurial preparations, concen- 
trated acids, and strong, caustic alkalies. 

4. Enteritis may be caused by mechanical irritants. 
Thus hardened scybala, biliary calculi, enteroliths, or 
foreign bodies which have been swallowed, like large ker- 
nels of fruit or coins, may evoke inflammation. The 
catarrh accompanying intestinal worms may also be placed 
in this group. 

5. Intestinal catarrh is very often due to variations in 
temperature or to catching cold. It seems that the dispo- 
sition to this agent varies in different individuals. Thus 
some people get an attack of diarrhoea if they sleep uncov- 
ered during the summer and a drop in temperature occurs, 
the colder atmosphere affecting the abdomen. Others, 
again, are attacked with diarrhoea whenever they get their 
feet wet. How the influence of cold acts in causing the 
enteritis is difficult to say. Some writers believe that the 
sudden change in the circulation of the blood caused by 
the cold is the principal factor ; others again explain it on 
the ground of a more favorable development of micro- 
organisms during the change of temperature. 

6. Auto-intoxication. Poisonous substances may develop 
in the intestinal tract and cause diarrhoea. The enteritis 
following large burns of the skin belongs to this group. 
Here the poisonous substance is probably formed at the 
site of the burned skin and carried by the blood current 
into the intestinal tract. 

Secondarv catarrh of the intestine occurs in almost all 



88 DISEASES OF THE INTESTINES. 

acute infectious diseases in the same way as gastric catarrh. 
It is further found accompanying heart, kidney, and liver 
diseases, tuberculosis, diabetes, etc. Most organic dis- 
eases of the bowels are associated with intestinal catarrh, 
as cancer of the intestines, volvulus, invagination, peri- 
tonitis, thrombosis. In this class of cases, however, the 
intestinal catarrh is of little importance compared with the 
primary affection. 

Morbid Anatomy. — The anatomical changes found in au- 
topsies are not always very well marked, and there is cer- 
tainly no exact relation between the intensity of the clinical 
symptoms and the severity of the pathological processes 
discovered. The mucous membrane of the affected part 
of the intestine appears reddened either over its entire ex- 
tent or only in spots. This red color is more pronounced 
around the follicles and patches, at the apex of the folds 
and of the villi. If the process is intense, extravasations 
of blood may be found. The mucous membrane appears 
swollen, sometimes cedematous, often it is covered with 
tenacious mucus. The villi and the solitary follicles are 
succulent and appear as whitish, small prominences sur- 
rounded by a red stratum (enteritis follicularis seu nodu- 
laris). If the process continues, these gray areas may 
rupture, and thus give rise to ulcerative lesions (follicular 
ulcers). Catarrhal ulcers also exist, however, caused by 
the loss in some places of the protective epithelial covering 
of the mucosa. Through extension of the inflammation in 
width and depth irregular losses of substance with under- 
mined edges are produced. Inflammatory irritation in the 
neighborhood of these defects may give rise to polypoid 
growths, especially when the process has run a protracted 
course. 

Microscopically the vessels of the mucosa and sub- 



ACUTE INTESTINAL CATARRH. 89 

mucosa appear in a more or less congested state. Small 
extravasations often exist between the glands of Lieber- 
kuehn. The spaces between the glands are frequently 
widened and filled with an abundant accum alation of round 
cells. The epithelium of the mucosa has mostly disap- 
peared, especially in the large bowel. But according to 
Nothnagel this may be a post-mortem phenomenon and not 
always the result of inflammation. Desquamative processes 
in the epithelial layer, however, occur during life caused 
by the catarrhal affection, for the changed eroded epithelial 
cells are found in the mucus voided with the stool. The 
glands often appear altered with regard to their contour, 
being wider at their fundus and much narrower at their 
mouth, frequently presenting a flask shape. The sub- 
mucous tissue is usually somewhat hyperplastic, otherwise 
not much changed. The muscular and serous coats are 
not affected. 

Symptomatology .— Intestinal catarrh usually manifests 
itself through a feeling of fulness in the lower part of the 
abdomen, colicky pains appearing from time to time, and 
diarrhoea. As a rule, no fever is present except in cases of 
a severe type. The number of the stools and their quality 
vary a great deal. In mild cases there may be only two or 
three movements in twenty-four hours; in severer cases 
fifteen to twenty diarrhceal evacuations. The first passage 
as a rule still contains normal fecal matter in its first por- 
tion, while the second part is of a mushy character. The 
next movements are semi-fluid, and at last entirely liquid 
dejecta may appear. The first stool still has a brown color 
and the characteristic fecal odor, while the following evac- 
uations present a slightly yellowish color or even a grayish 
appearance, occasionally resembling rice-water. The latter 
are sometimes devoid of fecal odor, have an acid reaction, 



90 DISEASES OF THE INTESTINES. 

and show a foamy surface. Mucus is almost always pres- 
ent. The fecal matter in its yellow parts contains, as a 
rule, unchanged biliary substances which give a charac- 
teristic Gmelin reaction. Microscopically undigested food 
particles may be discovered in larger than normal amounts ; 
thus meat fibres and well-preserved granules of starch 
may be observed. A host of micro-organisms, epithelial 
cells, sometimes in contiguous groups, and mucus are 
found. Very seldom and only in severer cases small 
amounts of pus and red blood corpuscles may be dis- 
covered. Chemically peptones and sugar may be found in 
the dejecta. 

General Subjective Symptoms. — Aside from the diarrhceal 
movements and the unpleasant sensations consisting in a 
feeling of pressure and fulness in the abdomen mentioned 
above, there may in light cases be perfect euphoria ; usu- 
ally a feeling of weakness exists which is especially marked 
in the lower extremities. A feeling of dizziness and slight 
nausea often also appear, especially shortly before and 
during evacuations. Vomiting may also occur, as a rule, in 
cases in which the stomach is likewise affected or when the 
process of inflammation is of a severer type (cholera nos- 
tras). Tenesmus is frequently present, if the process is 
in the lower part of the colon, even if not especially pro- 
nounced. This seems to be the result of the irritating 
action of the dejecta upon the rectum. 

The general symptoms above described are much more 
pronounced in children and very old people. Here the 
appearance of collapse (cold extremities, blue lips, and 
apathy) is not very rare. Marshall Hall J has described a 
condition under the name of acute hydrocephaloid disease 

1 Marshall Hall : "Diseases and Derangements cf the Nervous Sys- 
tem, " London, 1841, p. 153. 



ACUTE INTESTINAL CATARRH. 91 

which occurs in weak children with acute enteritis. The 
hydrocephaloid appears in consequence of severe attacks of 
gastro-enteritis with a temperature of 104°-106° F. There 
is sudden collapse. While the body is hot, the extremi- 
ties become ice cold, the fontanelles sink in, the pulse 
becomes considerably accelerated, soft, and often irregular. 
In this condition the little patient lies apathetic unless 
suddenly disturbed with colicky pains when he utters a 
cry. The pupils do not react alike and the conjunctival 
reflex may be absent. Sometimes paralysis of the rectum 
is present, which I have seen in one case. In this condi- 
tion the patient often dies within a short time from paraly- 
sis of the heart. 

Objective Symptoms. — The physical examination of the 
abdomen occasionally reveals on inspection a bloated con- 
dition and some spots tender to pressure. As a rule, the 
lower part of the abdomen, particularly the immediate 
neighborhood of the navel, is slightly painful on palpation. 
Occasionally there may be found a decided tenderness, 
either in the right or in the left iliac region. Sometimes 
this tenderness may be quite pronounced in a line running 
across the abdomen between the margins of the false ribs 
(transverse colon). Palpation often elicits gurgling sounds 
caused by intestinal coils distended with gas and fluid con- 
tents. This phenomenon is most frequently observed in 
both iliac regions. 

In patients with thin abdominal walls peristaltic move- 
ments of the small intestine may be visible either sponta- 
neously or after palpatory examination. 

The urine is voided in small quantities, is concentrated, 
and often shows Kosenbach's reaction (Burgundy red color 
after boiling with nitric acid), and also contains indican 
(this especially if the process involves the small intestine). 



92 DISEASES OF THE INTESTINES. 

Casts and small amounts of albumin are sometimes found 
in the urine, especially in severer cases (Fisclil 1 ). 

Fever. — In the greater number of instances there is no 
rise of temperature during the course of this affection. In 
some cases, however, fever is quite a prominent symptom, 
and the disease may commence with violent chills and a 
marked elevation of temperature (104°) . The temperature 
may either fall suddenly on the next day or after the lapse 
of a few days, but it does not show that regular steady rise 
which is characteristic of typhoid fever. Fever is espe- 
cially met with in those cases of acute enteritis which are 
caused most probably by infection (either pathogenic micro- 
organisms or tainted food) . 

Localization of the Catarrhal Process. — In order to find 
out what part of the bowels is especially affected the fol- 
lowing points are of value : 

A duodenitis may be recognized if the above symptoms 
are accompanied by icterus. Intestinal catarrh attended 
with a constant painful sensation in the right epigastric 
region, which, besides, is also tender to pressure, indicates 
more or less a continuation of the catarrhal process from 
the stomach to the duodenum. Pains appearing in the 
same region after extensive burns of the skin also point to 
a duodenal affection, even if there be no icterus. 

Jejunitis alone or jejunitis and ileitis without any affec- 
tion of the large bowel can be diagnosed only with diffi- 
culty, for the principal symptom of enteritis (namely, that of 
diarrhoea) is as a rule absent. Small amounts of mucus well 
mixed with fecal matter, a considerable quantity of undi- 
gested food particles, and epithelial cells tinged with yellow 
bile pigment in the faeces, point to a catarrhal condition 
of the small intestine. Indicanuria is also often present. 
1 Fisclil : Prager Vierteljahresschr., 1878, Bd. 139, p. 27. 



ACUTE INTESTINAL CATARRH. 93 

Acute colitis is characterized by painful sensations and 
a greater tenderness on pressure over the entire colon. 
The stools are diarrhceal and contain large quantities of 
mucus. The latter as well as the fecal matter may contain 
undecomposed biliary pigment. Sigmoiditis, described by 
Mayor 1 and later by Boas 2 and Mathews, 3 means an in- 
flammatory process involving the sigmoid flexure, and is 
recognized by .special tenderness on palpation of this por- 
tion of the bowel, intense backache, and a frequent dis- 
position to go to stool. 

Proctitis, or inflammation of the rectum , is characterized 
by severe tenesmus and colicky pains in the left iliac fossa. 
The patients have a constant desire to go to the closet, but 
at each time void only small quantities of fecal matter 
under the greatest pains. The scybala are surrounded by 
a layer of mucus which may be tinged with blood. Occa- 
sionally the mucous membrane of the rectum prolapses 
during defecation. It then appears intensely dark red and 
is extremely painful to the touch. Even if not prolapsed, 
a digital rectal examination is attended with much pain. 
The mucous membrane of the rectum feels hot and the ex- 
amining finger on removal sometimes shows traces of blood. 

Duration. — The duration of acute enteritis varies consid- 
erably. Mild cases improve in about two to five days, 
while those of a severer type may last about two weeks. 
After recovery from acute enteritis the intestinal tract 
remains quite sensitive for a long time. If no attention is 
paid to this condition and gross errors of diet are com- 
mitted, relapses are liable to occur. Several relapses may 

1 A. Mayor : Revue med. de la Suisse Romande, 1893, No. 4. 

2 J. Boas : "Krankheiten des Darms, " ii., p. 513. 

3 Mathews : "Disease in the Sigmoid Flexure. " The American Med- 
ical Quarterly, June, 1899. 



94 DISEASES OF THE INTESTINES. 

also follow each other and ultimately cause a chronic en- 
teritis. 

Diagnosis. — As a rule the recognition of acute enteritis 
is very easy. The characteristic diarrhoea, the admixture 
of mucus in the dejecta, the fact that a dietetic error has 
been committed, or that the abdomen (or other parts of the 
body ) has been exposed to cold, will all indicate the nature 
of the affection. The localization of the process, whether 
affecting more or less the entire intestinal tract or only 
certain parts, is more difficult, and the important points of 
differentiation have already been given above. Frequent 
vomiting and very pronounced general symptoms (espe- 
cially collapse) point to cholera nostras, which is the most 
severe form of acute enteritis. If the diarrhoea is accom- 
panied by high fever, urinary casts, and pains in the mus- 
cles and joints, then the assumption of an acute enteritis 
of an infectious type is justified. 

Prognosis. — The prognosis of acute enteritis is, as a rule, 
good, the disease tending to recovery in a very short time. 
In children, however, and very old and weakened persons, 
the course of the disease is sometimes not so favorable and 
may lead to collapse and even to death. 

Treatment. — In mild cases of acute enteritis no medicinal 
treatment will be necessary. Abstinence from food for one 
or two days, allowing the patient to take only weak tea, a 
small quantity of bouillon, and some boiled water may suf- 
fice to check the attack. Sometimes, however, especially 
if the attack of enteritis has been caused by dietetic errors, 
and fulness of the abdomen and frequent colicky pains in- 
dicating that irritating substances are lodged within the 
intestines are present, a good old-fashioned drastic is in 
place. Thus castor oil — about one ounce — may be given 
or calomel 0.6 (gr. x.), the latter being preferable in cases 



ACUTE INTESTINAL CATARRH. 95 

of a probably infectious nature. If there is no fever and the 
symptoms are mild, then the patients may be up and about, 
although it is always advisable for them to keep quiet more 
or less. In cases of a severer type, and especially those with 
fever, the patients should stay in bed until the symptoms 
are entirely subdued. If the diarrhoea shows no signs of 
abating after a day or two, or if the symptoms occur so 
frequently as to be debilitating, then an opiate is in place. 
Tincture of opium, seven drops every three hours, or co- 
deine, 0.02 or 0.03 (gr. £-- J) also every three hours, may 
be given. Frequently the combination of an opiate with 
subnitrate of bismuth and chalk or w r ith tannigen may be 
useful. Thus I often prescribe the following powders : 

1$ Bism. subnitr 6.0 (3 iss.) 

Cret. pulv 3.0 (gr. xlv.) 

Cod. phosph 0.1 (gr. iss.) 

Elseosacch. menth. pip 5.0 (gr. lxxv. ) 

Misce f. pulv. Div. in p. seq. No. x. S. One powder three or 
four times a day. 

Or— 

1$ Morph. muriat 0.1 (gr. iss. ) 

Tannigen, 

Elaeosacch. menth. pip aa 5.0 (gr. lxxv.) 

Misce f. p. Div. in p. seq. No. x. S. One powder three times 
daily. 

Calumba, cascarilla, catechu, kino, may also be employed, 
twenty to thirty drops of the tinctures being given about 
three times daily. Another useful remedy is dermatol, 
which may be administered in doses of 0.5 gm. (gr. viii.) 
three times daily. In cases in which the entire colon 
or its lower part is affected, irrigation of the bowels with 
astringent solutions is of great benefit. This may be done 
with a solution containing nitrate of silver, 0.3 (gr. v.) 



96 DISEASES OF THE INTESTINES. 

to 1,000 (one quart) water, or tannic acid, 2 to 5 gm. 
(30 to 80 grains) to 1,000 water, or liquor ferri sesqui- 
chlor. 2 : 1,000. It is best to inject these solutions after 
a previous washing out of the bowel with plain water or 
soon after a movement. The astringent solution should 
be allowed to remain for about five to ten minutes, but in 
case the patient is not able to retain it for even so short a 
time, fifteen to twenty drops of tincture of opium may be 
added to the injection. This, as a rule, lessens the irrita- 
tion of the rectum and the patient is thus able to hold the 
enema longer. The temperature of the water should be 
tepid. All the above-mentioned astringent remedies have 
also slight antiseptic qualities. In cases, however, in 
which the fermentative processes within the bowels are 
especially pronounced, the following stronger antifermen- 
tative substances may be used for irrigation : salicylic acid, 
2 : 1,000 water, or salicylate of sodium, 10.0 ( 3 iiss.) : 
1,000; boracic acid, 5.0:1,000; creolin, 1.0 (gr. xv.) : 
1,000. 

If pains are present a warm poultice or a hot-water bag 
over the abdomen is very beneficial. 

Cold drinks should be forbidden. Warm teas, fennel or 
camomile, are useful; on the second or third day the pa- 
tient can be nourished with soups or gruels (barley, rice, 
oatmeal soup cooked with or without milk) ; water soup 
(stale bread softened in hot water with the addition of a 
little butter and salt) and hot spiced claret are then in 
place. A little later toasted bread, crackers, soft-boiled 
eggs may be added to the diet; still later, scraped meat, 
lamb chops, tenderloin steak, bread and butter. As soon 
as the diarrhoea has entirely stopped we may allow mashed 
or baked potatoes in addition to the other articles. For 
quite a while after an attack of enteritis the patient has to 



CHRONIC INTESTINAL CATARRH. $? 

be careful with vegetables and especially fruits. The first 
he may begin to take in small portions soon after an at- 
tack, while the latter should be avoided for a somewhat 
longer time. 

In secondary enteritis the principal primary affection 
must be considered first. Thus enteritis accompanying 
malaria will be best remedied by quinine. Enteritis ac- 
companying affections of the lung, heart, or liver must be 
treated after due attention has been given to the primary 
affection. 

CHRONIC INTESTINAL CATARRH. 

Synonyms. — Enteritis chronica; Chronic catarrh of the 
bowels. 

Definition.— An affection characterized by a chronic 
inflammation of the intestinal mucosa, giving rise to vari- 
ous disturbances in the function of the bowels. 

Etiology. — Chronic intestinal catarrh may arise either 
from a severe acute enteritis which shows no tendency to a 
cure, or (most often) from repeated attacks of acute enter- 
itis following each other at short intervals before the bow- 
els have had a chance to recover fully. This often occurs 
in patients who do not pay sufficient attention to their 
apparently slight trouble and disregard the dietetic rules 
prescribed by the physician. The direct factors causing 
chronic enteritis are the same as those of the acute condi- 
tion. Like acute enteritis, chronic intestinal catarrh may 
be divided into a primary and a secondary form, the pri- 
mary being idiopathic, while the secondary appears in 
connection with affections predisposing to this condition. 
Thus diseases of the lungs, especially tuberculosis, affec- 
tions of the heart, liver, and kidneys, and diabetes are often 

accompanied by chronic intestinal catarrh. Intestinal 

7 



98 DISEASES OF THE INTESTINES. 

parasites, round worms, tapeworms, etc., are quite often 
the cause of a secondary chronic enteritis, due to the irri- 
tation of the intestinal mucosa which they evoke. 

Morbid Anatomy. — The anatomical changes in chronic 
intestinal catarrh are similar to those of the acute condition 
and are characterized by hyperemia, swelling, and in- 
creased secretion of the mucous membrane. However, 
instead of the bright red or intensely dark red color seen 
in acute catarrh, the mucosa in the chronic form presents a 
grayish brown-red tint. The blood-vessels are greatly dis- 
tended, and often curved into a serpentine shape. In cases 
of long duration the intestinal mucosa frequently appears 
of a slate color intermingled with black pigment (changed 
red blood pigment which has escaped from the blood-ves- 
sels). These black dots are often found accumulated at 
the tips of the villi and also in the immediate neighborhood 
of the lymph follicles and of the glands of Lieberkuehn. 
The surface of the mucosa is as a rule covered with a 
viscid and trans parent mucus. The epithelial cells are 
cloudy, in a condition of fatty degeneration, and partly 
desquamated. The interstitial tissue is infiltrated with 
cellular elements. The glands themselves are of irregular 
shape, sometimes elongated and tortuous, occasionally 
much smaller than normally. In cases in which there is 
an interstitial tissue proliferation, a constriction around 
the neck of a gland arises. As a consequence there is 
retention of the glandular secretion, and ultimately a cyst 
may develop. Hyperplastic processes around the inflamed 
area very often lead to the formation of polypi. The latter 
as a rule consist of muscular and fibrous tissues and con- 
tain no glands. Exceptionally polypoid excrescences may 
appear on the intestinal mucosa (especially in the colon), 
which consist of a real proliferation of the intestinal mil- 



CHRONIC INTESTINAL CATARRH. 99 

cosa containing glands. An excellent instance of this rare 
occurrence has been described by Woodward. 1 

In some of the most advanced cases, atrophy of the 
mucosa may be present. As in the stomach, this process 
may arise from two entirely different conditions. In the 
one the process originates in the glandular tissue ; the lat- 
ter becoming inflamed, the seat of fatty degeneration, and 
ultimately atrophied. In the second group the process 
leading to atrophy originates from an interstitial tissue 
proliferation; the connective tissue becoming liypertro- 
phied, compresses the glands, and, gaining the upper 
hand, ultimately leads to their entire disappearance. 
These atrophic processes, as a rule, do not extend over 
the entire intestine, but more often involve certain parts. 
Thus, the csecuni and its immediate neighborhood have 
often been found in this state, even in persons who ap- 
parently during life had no intestinal affection (Noth- 
nagel). Large portions of the small and large intestines 
or the entire intestinal tract are but rarely found atro- 
phied, more often in children than in grown-up persons. 
Ewald 2 mentions that he has observed this rare condition 
in six autopsies in adults. They all had suffered during 
life from pernicious anaemia and gastro-intestinal disturb- 
ances. 

Both the hyperplastic and atrophic processes, as a rule, 
are not limited to the intestinal mucosa alone, but also in- 
volve the neighboring structures (the submucosa and the 
muscularis). Thus in the hyperplastic form the thickness 
of the wall of the small intestine may be increased to six 
times its normal size, while the large bowel may become 

1 Woodward : L. c. 

2 C. A. Ewald: " Diseases of the Intestines." Twentieth Century 
Practice of Medicine, vol. ix., p. 127. 

LofC. 



100 DISEASES OF THE INTESTINES. 

three times as thick as normally. In atrophy of the intes- 
tine there is also a degeneration of the muscles. The gan-> 
glionic cells of the Meissner and Auerbach plexus have been 
found in a state of fatty degeneration, smaller and lessened 
in number in the atrophic form ( Jurgens ] and Sasaki 2 ) . 
Whether these changes in the nervous tissue are the cause 
or the result of this general intestinal atrophy is as yet not 
known. 

Several varieties of ulcerative processes exist complicat- 
ing chronic intestinal catarrh. Some ulcerations arise in 
consequence of superficial erosions of the mucosa, which 
do not heal. The defect, once produced, gradually grows 
deeper. Several superficial ulcers adjacent to each other 
may grow larger and unite. Thus a considerable irregu- 
lar ulceration develops. The ulcerative process increasing 
in depth may lead to a secondary phlegmonous inflamma- 
tion of the submucosa, and ultimately to perforation of the 
intestinal walls. Another danger lies in the ulcerative 
process involving a blood-vessel which may cause hemor- 
rhage. If the perforation through the intestinal walls oc- 
curs rapidly, fatal peritonitis results ; but if the perforative 
process develops slowly, then agglutination takes place 
and a localized peritonitis with or without the formation 
of a fecal abscess follows. These eventualities are, how- 
ever, rare. Generally the ulcerations either remain un- 
changed (not progressing) for a long period of time or they 
cicatrize. In the latter event strictures of the intestinal 
lumen may occasionally develop. 

Follicular enteritis is also occasionally the cause of the 
formation of an ulcer. The lymph nodules swell up to pea 
size, soften, and burst. A small ulcer thus arises. As a 

'Jurgens: Berl. klin. Wochensch., 1892, p. 357. 
2 Sasaki : Virch. Arch., Bd. 96, p. 287. 



CHRONIC INTESTINAL CATARRH. 101 

rule, healing takes place, the mucosa of the immediate neigh- 
borhood extending over and gradually overlapping the de- 
fect. Sometimes, however, the ulcerative area is covered 
with a layer of mucus secreted by the goblet cells of the 
neighboring glands. From time to time the accumulated 
mucus is removed from the defect and appears in the dejecta 
in form of particles resembling sago. Extensive ulcerations 
are seldom met with in chronic enteritis. Most often they 
occur in the enteritis accompanying pulmonaiy tubercu- 
losis. 

Symptomatology. — Chronic intestinal catarrh may occa- 
sionally exist without giving rise to any subjective com- 
plaints. As a rule, however, there is a feeling of discom- 
fort and sometimes of slight pains in the abdomen. These 
abnormal sensations may be especially marked some time 
after the ingestion of food or shortly before the evacua- 
tions. In some cases, again, these annoying sensations 
appear early in the morning, about an hour or two before 
rising. Borborygmi often occur; occasionally there is a 
feeling of tension or of bloating in the abdomen, which 
may be relieved by the passing of flatus. The latter symp- 
tom may be so constant and annoying that the patient is 
afraid to appear in society or may be hindered in his voca- 
tion. An accumulation of gases in the intestine, especially 
in the colon, may sometimes exert pressure upon the dia- 
phragm and give rise to asthmatic complaints, palpitations 
of the heart and angina pectoris, congestion of the head 
and vertigo. Belching or passing of wind alleviates these 
symptoms or entirely removes them. 

Colicky pains sometimes appear and are of short dura- 
tion. Severe pains, however, are almost always ab- 
sent. 

If the catarrh has lasted for some time, then symptoms 



102 DISEASES OF THE INTESTINES. 

relating to the general state of health often appear. Thus 
the patient may feel weak, show a disinclination to work, 
be irritable and somewhat melancholic. Some patients 
greatly lose in flesh, and present an appearance of suffer- 
ing, have cold extremities and a slow pulse. Headaches, 
nausea, and anorexia are also often met with. 

Whether these symptoms are due to auto-intoxication as 
some, especially of the French writers, assume (Bouchard ') 
is very difficult to state. It is, however, certain that this 
theory does not apply to all cases of this kind. 

Gastric symptoms (nausea, anorexia, etc.) are as a rule 
met with only in cases in which the small intestine is 
affected. If the catarrh is limited to the large bowel these 
symptoms are usually absent. 

Objective Symptoms. — In some cases the abdomen is 
bloated, especially shortly after meals, and somewhat ten- 
der to pressure. There may be tenderness all along the 
colon ; occasionally the ascending colon can be felt as a 
sausage-like body containing hard masses, which change 
their shape upon digital pressure, or this part of the colon 
is filled with gas and liquids and a splashing sound can 
then be easily evoked. Similar phenomena may be ob- 
served also in the descending part of the colon (S Eoma- 
num) in the left iliac fossa. Tenderness along the colon 
upon pressure is often found ; usually the pains are felt 
just beneath the area where the pressure is exerted; some- 
times, however, the pain appears in a more remote spot. 
Thus, for instance, upon pressing upon the ascending co- 
lon in the right iliac fossa, pain is felt across the abdomen 
in a line lying horizontally at two fingers' width above 
the navel (transverse colon). Intestinal peristalsis may be 
observed in persons with thin abdominal walls, especially 
Bouchard: " Let^ons sur les Auto-intoxications, " Paris, 1887. 



CHRONIC INTESTINAL CATARRH. 103 

after a palpatory examination. All these signs, however, 
are occasionally absent. 

In the symptomatology of the chronic intestinal catarrh 
the character and frequency of the stools are of greatest 
importance. While in acute intestinal catarrh diarrhoea is 
almost a constant characteristic symptom, there is much 
variation in the frequency of the dejecta in the chronic 
form. With regard to this point Nothnagel divides cases 
of chronic intestinal catarrh into the four following groups : 

1. Cases characterized by pronounced constipation. An 
evacuation appears only once in two, three, or four days ; 
sometimes only with the aid of cathartics. The fecal mat- 
ter is usually hard. As a cause of the constipation, Noth- 
nagel assumes a decreased activity of the automatic nervous 
apparatus of the intestines, this being the result of the ca- 
tarrhal process. 

2. Cases in which constipation and diarrhoea constantly 
alternate. For two or three days there may be a daily 
evacuation of very hard dejecta. On the following day 
there may be four to six very thin or mushy movements 
mixed with mucus, accompanied by violent pains, and then 
again constipation for a day or two, etc. Or there may be 
quite normal evacuations (once daily) for a few days in 
succession and then again four to seven diarrhceal move- 
ments in one day, and after this constipation. The prin- 
cipal feature of these cases is the constipation, but the 
excitability of the nervous apparatus being quite good, 
the decomposed stagnant contents often cause increased 
peristalsis and diarrhoea. Sometimes these alternating 
periods of constipation and diarrhoea continue for a long 
time. Thus the patient may be constipated for four or 
five weeks, or even for a few months, and then again the 
diarrhoea may set in, lasting several weeks or months. 



104 DISEASES OF THE INTESTINES. 

3. In a very limited number of cases there is a daily 
evacuation, which is usually not formed and mushy. 

4. Cases in which there are for months several diarrhoeal 
evacuations daily. The dejecta as a rule show the biliary 
reaction, or they may contain yellow fragments of mucus, 
yellow tinged epithelia, and round cells. In these cases 
the catarrhal process affects not only the large bowel but 
also the small intestine. The absorption suffers and there 
are more abnormal products in the contents (acids), which 
give rise to increased peristalsis in the small as well as 
large bowel. 

Besides these typical cases there are some in which the 
nervous element plays a part in combination with the ca- 
tarrhal process. Thus there are patients who are molested 
with diarrhoeal movements only during the night or in the 
early morning hours (morning diarrhoea of Delafield 1 ), 
while they feel well during the remainder of the day. 

The quality of the dejecta in those cases in which there 
is constipation is almost normal, with the only exception 
that there is an admixture of mucus. Nothnagel considers 
this point the most important in the recognition of a 
catarrhal condition of the intestine. The mucus may be 
absent in rare instances in which the scybala are small and 
the layer of mucus within the intestine is very tough and 
adherent, so that the fecal matter cannot carry it along in 
its passage. 

The quantity of mucus varies greatly. While in most 
cases only small particles of mucus are found, there are 
some in which a considerable amount. may be passed. 
Large amounts of mucus without fecal matter are often 
found in enteritis membranacea, less frequently in chronic 
enteritis. 

*F. Delafield : Medical Record, May 11th, 1895. 



CHRONIC INTESTINAL CATARRH. 105 

In cases in which the dejecta are more or less thin, 
mushy or watery, the fecal matter has a light color, brown- 
ish-yellow or grayish-yellow, and may at times be very 
poor in biliary matters. In these instances, undigested 
food particles are easily found. Thus small particles of 
meat or starchy food may be discovered. 

The microscopical examination of the dejecta is often 
very useful, for even in cases in which macroscopically 
nothing abnormal can be discovered, the microscope may 
reveal considerable amounts of undigested meat fibres, 
starch granules, and fat globules. Such substances, if fre- 
quently present, indicate that the catarrhal affection is 
principally within the small intestine. The microscope 
here further shows the presence of epithelial cells, some- 
times of a yellow color and mostly in a shrivelled condi- 
tion and embedded in mucus. 

According to [Rosenheim, ' chemical examinations of the 
dejecta have no practical value in this affection. The reac- 
tion with regard to litmus varies greatly and is dependent 
upon the frequency of the stools and the quality of the in- 
gested food. As a rule, however, an alkaline reaction is 
found. 

The degree of fermentative processes in the intestines 
may be gauged by the intensity of the feeling of tension in 
the abdomen, the frequency of flatus, and the condition of 
the dejecta. The latter may present a very fetid odor and 
a foamy surface. If the movements are diarrhceal, a fer- 
mentation tube may be filled with the liquid contents and 
kept at blood temperature for a few hours ; the amount of 
gas developed in the tube will indicate the degree of fer- 
mentation. The character of the urine is also of impor- 

1 Theodor Rosenheim : " Pathologie und Therapie der Krankbeitea 
des Darms, " Wien und Leipzig, 1893, 



106 DISEASES OF THE INTESTINES. 

tance with regard to this point. In conditions in which 
there is considerable fermentation and absorption of de- 
composed products within the small intestine, it usually 
gives a more or less strong indican reaction and also a 
decided Eosenbach reaction (Burgundy red color after 
boiling and the addition of nitric acid). 

Chronic enteritis complicated with catarrhal ulcers mani- 
fests itself by more frequent attacks of diarrhoea, admix- 
ture of blood or pus in the dejecta, and pain. All these 
symptoms are especially apt to be present if the lower 
part of the intestinal tract is affected ; if the ulcer is in the 
small intestine, diarrhoea is often absent, nor need there 
be any signs of blood or pus in the dejecta. 

Atrophic processes may also accompany the enteritis. 
If these involve only a small part of the intestinal tract, no 
symptoms whatever may result; if, however, larger parts 
of the small intestine are affected, the absorption of food 
is greatly impaired and then severe symptoms occur. 
Diarrhoea without passage of mucus and accompanied by 
a gradual bat steady loss in weight is present, as are oc- 
casional symptoms of pernicious anaemia. This condition 
is found much oftcner in infancy than in later life. 

Course. — As a rule chronic enteritis is a very tedious 
affection. It may last many years, even until the end of 
life. The intensity of the symptoms varies a great deal, 
and there may be periods of apparent perfect euphoria. 
There always remains, however, a decided weakness of the 
intestine, which is easily upset by slight errors in diet, 
which in healthy persons would be harmless. 

Diagnosis.— The diagnosis of chronic enteritis is made 
if there are abnormal sensations within the abdomen, ac- 
companied by irregularity of the bowels and the presence 
of mucus in the stools. Habitual constipation can be ea- 



CHRONIC INTESTINAL CATARRH. 10T 

sily differentiated from enteritis : (1) by the absence of mu- 
cus ; (2) by the fact that it does not so easily nor so com- 
pletely respond to mild cathartics. Malignant growths 
are often accompanied by enteritis, and thus the symp- 
toms of the latter often give rise to mistakes. A longer 
period of observation, however, will aid in arriving at a 
correct diagnosis. In case of a neoplasm symptoms of 
cachexia will not fail to appear nor will the accompanying 
enteritis be so readily alleviated as if it were the only 
affection. In ulcer of the intestine pains predominate and 
are a marked feature. Constipation and diarrhoea depend- 
ent upon disease of the stomach will be recognized : (1) by 
the absence of mucus in the stools ; and (2) by an examina- 
tion of the gastric contents. They will readily yield to 
treatment directed toward the gastric disorder. 

With regard to the localization of the process, the fol- 
lowing is of importance: Chronic inflammation confined 
to the small intestine is usually accompanied by gastric 
symptoms, constipation, and the presence of small parti- 
cles of mucus in the stools, having a yellow tinge and being 
well mixed with the dejecta. If the large bowel alone is 
involved (colitis), there is constipation with the presence of 
more or less mucus of a grayish color, either covering the 
entire fecal mass or appearing here and there on its sur- 
face. Occasionally, especially if the lower part of the 
bowel is affected, the mucus appears at the end of the de- 
fecation and is then voided without any admixture of fecal 
matter. If the inflammatory process involves both the 
small and the large intestines, constant diarrhoea is a pre- 
dominant feature. The mucus found in the dejecta has a 
yellowish color; besides considerable quantities of undi- 
gested food are discovered in the fecal matter. 

Prognosis. — The prognosis of chronic enteritis depends 



108 DISEASES OF THE INTESTINES. 

upon the intensity of the symptoms, the duration of the 
disease, and also greatly upon the age and the constitution 
of the patient. In infancy and in old age chronic catarrh 
of the intestines must be considered a grave affection. 
The same applies to persons with a weakened constitution 
(tuberculosis, cardiac or other important lesions). A 
chronic enteritis of intense type which has lasted a long 
period of time is hardly ever cured perfectly. There may 
be improvements in the condition of the patient, but re- 
lapses are sure to follow soon. Cases of a mild nature, how- 
ever, often end in recovery, especially under an appropriate 
treatment. In old age a complete cure rarely takes place. 
If atrophy of the intestines has developed, then the condi- 
tion is very unfavorable, the patient succumbing after a 
period of about twelve to eighteen months. 

Treatment. — As in the treatment of chronic gastric ca- 
tarrh, and perhaps in a still greater degree, hygienic and 
dietetic measures here play the chief part. It will be at 
first important to regulate the mode of living of the patient 
■ — not too much work, not too great business strain, plenty 
of outdoor life and exercise, regularity of meals. Expo- 
sure to cold should be carefully avoided. The patient 
should dress warmly, especially the abdomen and feet (flan- 
nel bandage around the abdomen), and should be particu- 
larly careful not to get his feet wet. In rainy weather shoes 
with thick soles or rubbers should be worn. With regard to 
diet the following rules are of value : the meals should be 
taken frequently and in small portions. Indigestible sub- 
stances should be avoided. Sufficient nourishment should 
be given, and care taken that there is an increase rather 
than a decrease in weight. In cases of diarrhoea the fol- 
lowing should be forbidden : acid or sweet wines, all mine- 
ral waters charged with carbonic-acid gas, lemonade, all 



CHRONIC INTESTINAL CATARRH. 109 

kinds of fruits, salads, all kinds of cabbage including cauli- 
flower, rye bread, and pastries. Give eggs (soft-boiled 
or scrambled), light meats, especially sweetbread, calf's 
brain, spring chicken, steak, lamb chops, oysters, lean fish, 
white bread well baked or toasted, fresh butter, cream 
soups, bouillon, rice, sago, macaroni, mashed or baked 
potatoes, milk, cacao, tea. Kumyss, matzoon, ginger ale, 
good claret or Tokay may also be allowed. As a rule noth- 
ing should be taken in large portions, and the drinks should 
be warm or cool (temperature of the room), but not cold. 
Large amounts of liquids should be avoided. Patient with 
very severe symptoms (frequent diarrhoea, intense pains, 
great weakness) must be kept abed for a short time and 
put on a rigorous diet at first, as in cases of acute ente- 
ritis. Upon improvement of the condition the dietetic 
rules described above should be followed. 

In cases attended with constipation the diet may be more 
liberal. Besides all the articles of food mentioned in the 
diarrhoeal group, light fruits, as oranges, grapes, ripe 
pears, and green vegetables, green peas, cauliflower may 
be added. The ingestion of large amounts of starchy 
foods, easily assimilated fats, butter, cream, and of fluids 
is very beneficial. The more indigestible articles of food, 
like bran breads (pumpernickel), sausages, lobster salad, 
mayonnaise dressings, cabbage, cucumbers, etc., should 
be avoided. Beer, ale, Rhine wine taken moderately are 
permissible. 

Eydrotherapeutic Measures. — In cases of diarrhoea warm 
mineral baths or baths with the addition of pine needle 
extract and mud and bran baths are favorable. Cold baths 
should be avoided. A cold sponge bath, however, or a 
cold shower on the back may be serviceable in chronic en- 
teritis with nervous symptoms. A Priessnitz (wet pack) 



110 DISEASES OF THE INTESTINES. 

over the abdomen may be advantageously used over night. 
Cold sitz baths and cold showers over the abdomen are 
also often beneficial. 

Mineral Waters. — According to Nothnagel chronic enteri- 
tis is sometimes greatly improved, and even perfectly cured, 
by a methodical course of drinking certain mineral waters. 
Such a cure can best be carried out at the mineral springs 
themselves. For here the patients not only take the waters 
in the right way, but also observe the necessary rules of 
diet and are besides kept free from their business cares. 
Carlsbad is to be regarded as the best place in cases of 
chronic enteritis in which the diarrhoea is a prominent fea- 
ture; Vichy comes next. For cases of chronic enteritis 
with constipation Marienbad seems to be very useful; the 
same applies to Saratoga (Hawthorn and Congress 
Springs). For cases in which neither constipation nor 
diarrhoea plays a prominent part Kissingen or Homburg 
may be recommended. Chronic enteritis accompanied by 
angemia may be benefited at the watering-places of Fran- 
zensbad and Elster. The Carlsbad water should be taken 
in small quantities, about a wineglassful twice daily ; in 
some cases even smaller amounts (25 to 50 gm.) three 
to five times daily. In cases which have been benefited 
by a drinking cure in Carlsbad, Nothnagel suggests having 
these patients use at home the Carlsbad waters in a similar 
manner as at this resort, four times a year for an entire 
month. Nothnagel says : " The chronic condition requires 
a chronic treatment." 

Medicaments. — Strong cathartics should be avoided in 
the treatment of the constipation. Here some articles of 
diet which moderately increase the intestinal peristalsis 
may be first tried — buttermilk, a glass of cold water, 
stewed fruits, and the like. If these fail, small amounts 



CHRONIC INTESTINAL CATARRH. Ill 

of rhubarb, fluid extract of cascara sagrada, podophyllin 
may be used. Of greater value, however, are rectal injec- 
tions either of plain water or with the addition of some 
soap or salt (a teaspoonful to a quart) or Carlsbad water. 
Enemas of olive oil, as first recommended by Habershon 
and later by Kussmaul and Fleiner, may also be advan- 
tageously used. The oil enemas should, however, be 
given in small quantities (half a pint to a pint) and be re- 
tained over night in the bowels. The frequent use of calo- 
mel, castor oil, and jalap should be forbidden. 

The diarrhoea is best treated either by large doses of 
subnitrate of bismuth, salicylate of bismuth, or bismutose 
(1 to 2 gm., gr. xv.-xxx.) three times daily, or some of the 
drugs containing tannic acid as their principal ingredient 
(calumba, cascarilla, rhattania, catechu, kino, lig. campe- 
chianum, fructus myrtili). Weber ' recommends the fol- 
lowing prescription : 

I£ Extr. inonesiae, 

Extr. calumbae aa 15.0 ( 1 ss.) 

Extr. gent, et pulv. liq q.s. 

Ut f. pil. cxx. S. Three times daily two to four pills. 

I very frequently give fluid extract of condurango and 
fluid extract of calumba of each twenty drops three times 
daily. Dermatol (subgallate of bismuth) seems to be 
quite beneficial in cases in which the formation of gas is 
a predominant feature. It may be given in doses of half a 
grain (gr. viii.) three times daily. For the same condition 
salicylate of bismuth, benzonaphthol, and creosote in small 
doses may be given. Tannigen and tannalbin may be used 
in doses of 0.5 to 1 gm. (gr. viii.-xvi.) three times daily, 
the first being preferable. Both substances seem to less- 
en fermentation, and by their astringent qualities exert a 
'L. Weber: New-Yorker medicinische Monatsschrift. 1892. 



112 DISEASES OF THE INTESTINES 

beneficial influence upon the healing-process. They may 
therefore be given continuously for a long period of time. 

Cases accompanied by pains will require an opiate (mor- 
phine, or still better codeine), with or without the addition 
of belladonna extract. In chronic proctitis suppositories 
of opium and belladonna extract with cacao butter are indi- 
cated. Small enemas of starch solution with an opiate are 
also useful here. It is of course to be understood that the 
administration of opiates will have to be limited to a short 
period of time. 



CHAPTER IV. 

DYSENTEKY. 

Synonyms. — Enteritis crouposa et necrotica; Amoebic 
dysentery. 

Definition. — An infectious disease characterized by spe- 
cific ulcerations of the large intestine, giving rise to fre- 
quent bloody, mucous, or purulent dejections accompanied 
by tenesmus and general symptoms. 

Etiology. — Dysentery occurs under three different condi- 
tions : (1) As a disease principally during the warm season 
in temperate climates, appearing in local epidemics; (2) 
endemic in hot climates ; (3) epidemic at certain times in 
all latitudes, being quickly disseminated, and also sporadic. 
While the endemic zone of dysentery is limited to places 
lying south of the fortieth degree of latitude, epidemics of 
the disease have occurred in almost every part of the 
globe. Dysentery is one of the oldest diseases known. It 
was observed by Hippocrates and well described by Are- 
tseus and Celsus. Aretseus already recognized the ulcera- 
tion of the intestines in dysentery. 

Various causes have been adduced to explain the origin 
of the disease, and meteorological influences have been held 
responsible for its prevalence in local epidemics. The 
endemic dysentery of the tropics was generally ascribed to 
the combined action of heat and of the miasm of swamps. 
Sudden exposure to cold, eating of bad and spoiled food, 

and the use of stagnant or marshy water were all believed 

8 



114 DISEASES OF THE INTESTINES. 

to be factors in producing dysentery. It is only within 
recent years that its infectious and also contagious char- 
acter has been recognized. Sodre * says : " A careful etio- 
logical study shows that dysentery in whatever latitude it 
be observed is always due to the action of the same exciting 
cause, that it starts and is propagated always under the 
influence of infection and contagion, and that it should be 
included in the group of parasitic diseases." The exciting 
cause of dysentery often lies in the soil, in circumscribed 
foci of infection. These foci are represented by marshes 
and bogs which receive the drainage from dung heaps and 
cesspools, or by a soil impregnated with human dejec- 
tions. The contagious character of dysentery is best shown 
by the following report of Dr. Beauchef.' This writer 
states that the French ship Loreit, anchored on the west 
coast of Africa, was in the best possible sanitary condition, 
not one of the crew being ill. She was then ordered to 
transport to Gorea the sailors of the sloop of war Eagle, 
among whom were twenty-nine dysenteric patients. A few 
days afterward, while on the high sea, dysentery spread 
among the crew of the Loreit and ceased only after all the 
patients had been landed at Gorea. 

Among the causes which contribute to diffuse the dysen- 
teric contagion and to produce the disease in an epidemic 
form the following may be mentioned : Crowding together 
of individuals, the vicissitudes of war, bodily privation, 
chiefly hunger. These factors are frequently found asso- 
ciated in times of war when epidemics of dysentery have 
often appeared, causing great ravages. 

Since bacteria have been found to play an important 

1 A. Sodre : "Dysentery, " Twentieth Century Practice of Medicine, 
vol. xvi., p. 241. 
1 Beauchef : Cited after Sodre, loc. cit. 



DYSENTERY. 115 

part in the etiology of infectious diseases, many investi- 
gators have tried to discover the particular micro-organism 
producing dysentery. Various bacilli and cocci have been 
described and held responsible as etiological factors, but 
their relative significance has not been determined. As 
early as 1859, however, Lambl 1 called attention to the pres- 
ence of amoebae in the intestinal contents. He found them 
in the stools of a child suffering from dysentery. Loesch, 2 
in 1875, observed amoebae in the dejecta of a patient suffer- 
ing from chronic dysentery. He was the first to attribute 
the disease to this micro-organism. He also succeeded 
in experimentally producing a dysentery -like disease in 
a dog to which he had administered rectal injections of 
fecal matter containing amoebae. The observations of 
Loesch have been confirmed by Koch, 3 who, while investi- 
gating dysentery in Egypt, found in post-mortem examina- 
tions numerous amoebae in the intestine at the base of the 
ulcers. The next important contribution on this subject 
was made by Kartulis, 4 who, while practising in Alex- 
andria, had an opportunity to observe several hundreds of 
cases of dysentery. In more than five hundred post-mor- 
tem examinations he found the amoebae constantly in the 
faeces and on the surface of the ulcers, and in the abscesses 
of the intestine as well as of the liver. In other affections 
of the intestines Kartulis failed to detect the amoebae para- 
sites. He also succeeded in cultivating them in infusions 
of sterilized dry straw, and twice produced dysentery in 

1 Lambl : " Beobachtungen mid Studien aus dem Franz- Josef -Kinder- 
Spital, " 1860. 

2 Loesch : "Massenhafte Entwickelung von Amoeben im Dickdarm." 
Virch. Arch , Bd. lxv. 

3 Koch : Cited after Sodre, loc. cit. 

4 Kartulis : " Zur Aetiologie der Dysenterie in Aegypten. " Virch. 
Arch., Bd. 105, 1885. 



116 DISEASES OF THE INTESTINES. 

cats by inoculation with these cultures. Kartulis, there- 
fore, declared the amoebae to be the true etiological factor of 
dysentery. 

Yery soon afterward observations of a similar character 
were made both abroad and here. Thus Quincke and 
Roos, 1 Hlava, 2 Massaiutin, 3 Nasse, 4 and others abroad, and 
Osier, 5 Stengel/ Musser, 7 Eichberg, 8 Stockton, 9 Council- 
man and Lafleur, 10 and Harris 11 of this country have also 
described cases of dysentery with the presence of the 
amoebae parasites. 

The theory of the amoebic origin of dysentery has been dis- 
puted by some writers, for they have found this micro-or- 
ganism in the faeces in other intestinal disorders and, in 
some instances, even in the stools of healthy persons. Thus 
Schuberg 12 says : " The abundance of amoebae in dysentery 
is the effect and not the cause of the disease, the ulcerative 
lesions affording this habitual denizen of the intestines 
more favorable conditions for its development." The con- 
sensus of opinion, however, is that while harmless amoebae 
may occur in the intestinal tract, there exists a pathogenic 
variety of this organism which is specific for dysentery. 
For this reason Councilman and Lafleur proposed the name 

1 Quincke und Roos : Berl. klin. Wochenschr., 1893. 

2 Hlava: Centralbl. fur Bacteriologie, 1887. 

3 Massaiutin : Ibid. 

4 Nasse : Deutsche med. Wochenschr., 1891. 

5 Osier : Bulletin of the Johns Hopkins Hospital, 1890. 

6 Stengel : Medical News, November 15th, 1890. 

7 Musser: University Med. Magazine, December, 1890. 

8 Eichberg : Medical News, August 22d, 1891. 

9 Stockton : International Clinics, 1894, i. 

10 W. J. Councilman and H. A. Lafleur : " Amoebic Dysentery." Johns 
Hopkins Hospital Reports, vol. ii., Nos. 7-9, 1891, p. 395. 

11 K. F. Harris : " Amoebic Dysentery. " American Journal of the 
Medical Sciences, 1898, p. 384. 

12 Schuberg : Centralbl. fur Bakteriologie, 1893. 






DYSENTERY. 117 

of amoebae dysenteriae for this special variety. The pres- 
ence of the amoebae in the contents of abscesses of the liver, 
which are so often met with in dysentery according to 
Sodre, constitutes a powerful argument in favor of the 
amoebic etiology of the disease. 

It is generally believed that the amoebae enter the system 
along with the food or drink. Sodre believes that they can 
be taken in with the air. Certain waters, however, ap- 
parently constitute the principal means of propagation of 
these amoebae. Thus, Barthelemy ' relates that the troops 
when operating on the shore of the Oueme, whose clear run- 
ning water was filtered in Chamberland filters before being 
used, were in good health and free from dysentery ; when, 
however, the army moved away from the Oueme in the 
direction of Abomey they were compelled to use unfiltered 
swampy water. From that moment dysentery made its 
appearance. Fitz and Gerry 2 described a case of dysen- 
tery with the presence of amoebae in the stools and found 
the same micro-organisms in a cistern, the water of which 
the patients constantly used. 

The Bacillary Theory.— -In 1897 K. Shiga, 3 of Tokio, 
Japan, found a bacillus in the stools and intestinal walls 
of dysenteric patients. This bacillus (which forms a 
small, plump rod with rounded ends, resembling the colon 
bacillus) was present in all the cases of dysentery exam- 
ined by him, but was never found in healthy individuals 
or those affected with other diseases. Furthermore, it 
was plainly agglutinated by the serum of dysenteric pa- 
tients, and has since been accepted as the producer of dys- 

1 Barthelemy : " Medical Report of the War of Dahomey. " 

2 Fitz and Gerry : Cited after Sodre, loc. cit. 

3 K. Shiga: "Bacillary Dysentery." Twentieth Century Practice of 
Medicine, Supplement, p. 636. 



118 DISEASES OF THE INTESTINES. 

enteiy. In 1900 Flexner found the same bacillus in dys- 
enteric stools in Manila, and later in the United States. 
Kruse discovered the same bacilli in dysenteric patients in 
Germany. 

According to Flexner and Strong, there exist two types 
of dysentery —the bacillary and the amoebic. The first is 
produced by the bacillus dysenteriae and usually runs an 
acute course. The second is chronic and shows the pres- 
ence of no dysenteric bacilli, but the amcebge are found in 
the dejections and in the submucous tissue of the dysen- 
teric ulcers. This view is now generally accepted by most 
writers. 

Age does not seem to have any influence upon the disease. 
Statistically a greater number of cases is found among 
adults, as these are more exposed to the morbific causes. 
Both sexes are equally predisposed to dysentery, and no 
race enjoys immunity from it. One attack does not confer 
immunity against others. Persons who suffer from want 
of food or who live on food of bad quality are most liable 
to contract the disease. Harris says: "Dysentery is a 
disease pre-eminently of the poor, and is almost always 
associated with filth, bad hygienic surroundings, and lack 
of proper food." This statement, however, is somewhat 
too categorical, and I fully agree with Sodre, who remarks 
that dysentery is observed also in persons of the wealthier 
class, who live on the best food and are surrounded with 
every comfort. Nevertheless, it must be admitted that it 
is most frequent among the poor, and chiefly among people 
who live under bad hygienic conditions. 

Morbid Anatomy. — In acute dysentery the large intestine 
is almost always found in a thickened condition. This 
thickening involves all the intestinal coats, but is most 
marked in the submucosa. Sometimes the latter layer 



DYSENTERY. 119 

[.lone is involved. The mucosa, when washed with water, 
presents a bright red, at some places dark red color. The 
folds of the mucosa are much more voluminous than nor- 
mally, and thus present considerable prominences. Small 
red nodules of various size are also seen scattered over the 
mucous membrane. Besides these nodules more or less 
numerous ulcers are found. These vary greatly in size 
(from a pinhead to two inches long) and also in depth, 
some being superficial, others quite deep. The ulcers are 
situated chiefly on the folds of the mucosa. Ordinarily 
they are oblong and lie transversely to the long axis of 
the bowel. Sometimes they are circular, sinuous, or ir- 
regular. 

Councilman and Lafleur have described on the surface of 
the mucosa sharply outlined projecting nodular thicken- 
ings, in which are observed cavities filled with a gelatinous 
mass communicating with the surface of the mucous mem- 
brane by small openings, frequently not larger than the 
head of a pin. These writers have also pointed out as 
characteristic of the dysenteric ulcers their undermined 
edges. The disease process in dysentery, according to 
Councilman and Lafleur, is essentially one of advancing 
infiltration and softening of the submucous and intermus- 
cular tissue with subsequent necrosis of the overlying 
tissue. The anicebse reach the submucosa without injur- 
ing the mucous membrane. Here the essential changes 
are first produced, and the mucous membrane is interfered 
with later. The mucosa becomes cedematous and ruptures 
after a while, forming an ulcer. 

Harris described two anatomical forms of ulcers found in 
dysentery. In the first form, which is encountered most 
frequently and can be considered as the typical intestinal 
lesion of the disease, changes in the submucosa may be 



120 DISEASES OF THE INTESTINES. 

traced in advance of the surface ulceration for quite a dis- 
tance, thus undermining the comparatively healthy mucosa 
above. In the second form the ulcers increase in size by 
gradual softening and breaking down at the surface, never 
by necrosis and sloughing of the underlying tissue. Ul- 
cers of the second category occasionally do not penetrate 
deeper than half-way through the mucosa. Generally they 
extend into the submucosa. They never contain amoebae. 
According to Kartulis and Kruse, the first form is found 
in amoebic, while the second is encountered in bacillary 
dysentery. 

The lesions described are usually found throughout the 
entire large bowel, but as a rule they do not extend beyond 
the ileocecal valve. In a comparatively small number of 
cases the small intestine is also involved, principally the 
ileum. 

In some instances gangrene of the intestine is found. 
Many authors even describe a gangrenous form of dysen- 
tery. Sodre, however, does not regard the gangrene as a 
lesion brought on by the amoebae dysenteriae, but by the 
action of bacteria foreign to the dysenteric process. Ac- 
cording to this author gangrene is a complication of dysen- 
tery, but not a specific lesion. In this complicated form, 
besides the ulcers described above, there exist others of a 
gangrenous character. The gangrenous process may also 
extend beyond the ulcers. On the brownish-red mucosa 
gangrenous patches of a dark color and of various size are 
seen. In this condition the mucosa may be detached over 
a considerable area and eliminated with the dejections. 

In chronic dysentery the intestine is pale with slate col- 
ored spots. Its walls are thickened. The mucosa presents 
a pale rosy or slate color. Ulcers in different stages of 
development are encountered. Often the ulcers occur in 



DYSENTERY. 121 

groups separated from each other by more or less extensive 
healthy areas of intestine. Sometimes in certain portions 
of the intestines the ulcers become confluent. Dysenteric 
ulcers may be round, elliptical, or serpentine in form and 
usually have thickened and callous edges. In the neighbor- 
hood of the ulcers, there is no hyperemia or oedema, al- 
though an increase of fibrous tissue is noted. Undermined 
ulcers undergoing a process of repair are also found. The 
mucosa glands are found dilated and' filled with mucus. In 
some places glandular cysts of considerable size are encoun- 
tered, in others the glands have almost disappeared, and 
only traces of them are left. The mucosa is thickened and 
filled with round cells. The submucosa is likewise thick- 
ened and in some places cedematous. Dense fibrous tissue 
is found almost all over in this layer, predominating, how- 
ever, at the location of the cicatrices and of ulcers in the 
process of repair. 

In both the chronic and the acute form of dysentery, but 
principally in the latter, besides the lesion of the intes- 
tines described above, the liver is frequently found dis- 
eased. In dysentery complicated with gangrene this organ 
is usually greatly increased in volume, tumefied, soft, and 
friable. The cross-section presents a dark color inter- 
spersed with yellowish spots. The latter are usually some- 
what raised above the surface. On microscopical examina- 
tion the hepatic cells show a large amount of fat; besides, 
small round abscesses are found around the capillaries, 
which are most probably due to emboli. 

Aside from these very small pus collections of pyaemic 
origin, other abscesses are found which differ from these 
by their size and the nature of their contents. They are 
the so-called dysenteric abscesses of the liver, and are most 
often encountered in acute dysentery without gangrene. 



122 DISEASES OF THE INTESTINES. 

The dysenteric abscesses vary greatly in size from a few 
lines to several inches. They are situated chiefly in the 
right lobe of the liver near the surface. Often several axe 
found together. The contents of these abscesses vary 
greatly. In the most recent, the abscess does not empty 
itself on section. A small amount of glairy, semi-trans- 
parent fluid exudes and leaves behind an irregular sponge- 
like mass, the fluid being apparently held in the meshes. 
In the older abscesses the contents are more fluid, the latter 
having a greenish opaque color. In these are suspended 






m 



Fig. 30.— Amoebas from an Abscess of the Liver. X 750. (Sodre.) 

some solid masses of tissue. In some instances the con- 
tents are brownish or streaked with brownish-red from 
admixture of blood. Microscopical examination of the con- 
tents of the abscesses reveals the presence of a few pus. 
cells, a large quantity of fatty granules, necrotic hepatic 
cells, a few blood corpuscles, a great number of amoebae 
(see Fig. 30), and sometimes micrococci and bacilli. Ac- 
cording to Councilman and Lafleur, there is no definite 
abscess-wall, the liver tissue passes gradually into the 
abscess, and the contour of the edge is very irregular, 
sometimes extending into the liver for a distance of several 
nodules. The abscess may penetrate the capsule of the 
liver and either open externally or it may burst into some 



DYSENTERY. 123 

of the adjacent organs, as, for instance, the lungs, the 
stomach, the intestines, or the peritoneal cavity. Most 
often, however, it bursts into the lungs. 

Symptomatology of Acute Dysentery.— The disease may 
begin suddenly without any premonitory symptoms, or 
after a few days of general malaise, loss of appetite, and 
irregularity of the bowels, the patient is attacked with 
abdominal colic and diarrhoea. These symptoms are 
usually accompanied by chills, vague pains through the 
body, and fever. The stools, at first abundant and watery, 
very soon become scanty, mucous, and usually contain 
blood. Gastric disturbances are present in almost all 
cases: anorexia, nausea, often vomiting. The principal 
features of dysentery are the characteristic stools, the 
abdominal pains, and tenesmus. 

1. Stools. The evacuations increase in frequency, oc- 
curring from twenty to twenty-seven times during the 
twenty -four hours. The calls to stool are usually preceded 
by rumbling and colicky pains, and are followed by strain- 
ing and tenesmus. While during the first and perhaps the 
second day of the disease the motions are copious, they 
soon become scanty. The patient is then able to expel but 
a small quantity, about a teaspoonful of mucus mixed with 
blood, after painful efforts. Occasionally a few small 
pieces of fecal matter are passed. The dejecta occasion- 
ally change their character with regard to frequency as 
well as consistency. Intermissions and exacerbations of 
the diarrhoea are sometimes observed in the course of the 
disease. The mucus in the stools is almost always mixed 
with blood. In some cases the dejecta are hemorrhagic, 
that is, consist of almost pure blood, either red and fluid 
or dark and coagulated. In dysentery complicated with 
gangrene the stools are serous, of a dark reddish-brown 



124 DISEASES OF THE INTESTINES. 

color, and contain, in addition to finely divided mem- 
branous threads, large and thick masses of necrotic tissue 
of a gray or black color. The gangrenous dejecta have an 
intensely offensive odor. In many instances the stool con- 
tains no bile. 

Amoebae are almost always found in the dysenteric stools, 
especially if the lesions are quite extensive. In examining 
the faeces for amoebae it is well to use some precaution. 
If possible the examination should be made immediately 
after the dejecta have been passed. If this be impossible, 
the stool should be preserved in a clean vessel and kept in 
a warm place until the examination is made. The amoebae 
are from 12 to 36 /j. in diameter, and when alive frequently 
change their shape by contracting some part of their bodies 
in order to move about. The body of these micro-organisms 
consists of an outer clear homogeneous substance or ectosarc 
and an inner highly refractive mass or endosarc. Within 
the latter are usually found some bacteria, sometimes 
changed red blood corpuscles, and a few quite large 
vacuoles. The amoebae, when outside of the intestinal 
tract, die very quickly, especially if they are kept in a cool 
place. When dead, these organisms generally show a 
round or almost round configuration. 

In acute bacillary dysentery the bacillus dysenteriae 
(Shiga) is found in the fresh stools in almost pure culture 
in the latter half of the first week of the disease. 

(2) Abdominal pain. Abdominal pains exist with greater 
or less severity in almost every case. The pains may be 
experienced continuously, or principally before an evacu- 
ation. Most often they are located in the umbilical region 
and in the left iliac fossa, but sometimes they exist in the 
right iliac fossa and may then almost simulate an attack of 
appendicitis. The pains may be so severe that the patient 



DYSENTERY. 125 

is forced to lie perfectly still for fear of increasing them. 
Pressure exerted on the large intestine as a rule provokes 
more or less intense pain. According to Dutrouleau, ! in 
some very grave cases there is a total absence of colic 
during the entire course of the disease. 

(3) Tenesmus. Eectal tenesmus, consisting at first in 
painful sensations of pressure and constriction and later in 
an intense desire to go to stool, is encountered very fre- 
quently. In grave cases of dysentery the tenesmus may 
exist almost uninterruptedly. Off and on the patient suc- 
ceeds in expelling a small amount of fecal matter or slime or 
merely gas, and then feels relieved for a short while. Very 
soon, however, the pains in the anal region return with the 
same severity. When the tenesmus is very severe it may 
be accompanied by dysuria or strangury. In this condi- 
tion the patient presents a pitiable appearance. His 
straining is frequently agonizing and occasionally accom- 
panied by fainting. 

Besides the three cardinal symptoms of dysentery just 
described, other symptoms are often encountered. Fever 
may be present, especially in the severer form of the dis- 
ease. It may occur in the form of chills, when the disease 
is first ushered in. As a rule, the fever is not very high 
and shows an irregular course. Gastric symptoms are 
often present. They consist in intense anorexia, nausea, 
vomiting, and pain in the epigastric region. The general 
condition is more or less affected according to the severity 
of the disease. In grave cases prostration is marked, the 
skin is dry, the features are altered, and the extremities 
sometimes cold, The pulse is small and rapid. Some- 

1 Dutrouleau: "Traite des Maladies des Europecns dans les pays 
chauds," Paris, 1888. 



126 DISEASES OF THE INTESTINES. 

times cerebral disorders, stupor, drowsiness, even delirium, 
are encountered. 

Dutrouleau and others divide cases of acute dysentery 
into three groups: Cases of a mild character, those of 
medium intensity, and those of a severe type. In the mild 
form, there exist only local symptoms which are usually 
not very intense. In the form of medium intensity, the 
local symptoms are more accentuated and general symp- 
toms are encountered. In the severe form, there are fever, 
intense pain, very bloody stools, great prostration, and in- 
tolerable tenesmus. 

Symptomatology of Chronic Dysentery. —Chronic dysen- 
tery develops either after several attacks of the acute form 
or directly from the first acute attack, which after some 
periods of improvement persists to a greater or less extent. 
Cases of chronic dysentery are also divided into three 
categories: 

(1) The mild form. The general nutrition is not inter- 
fered with. The patients usually complain of slight con- 
stipation interrupted by light attacks of diarrhoea. Tenes- 
mus is either entirely absent or present in a very slight 
degree. Even during the attacks of diarrhoea the passages 
are, as a rule, not bloody. 

(2) Form of medium intensity. Here slight gastric symp- 
toms are present, like anorexia, belching, etc. The gen- 
eral condition is interfered with to a considerable extent. 
There are almost always periods of intermission and exac- 
erbation of the disease. The patient may have regular 
movements or be slightly constipated, for a period varying 
from a week to ten days, but soon diarrhoea appears and lasts 
for four or five days. The stools are then watery, contain 
mucus, and occasionally a little blood. Slight colicky 
pains are present, as well as moderate tenesmus and a sen- 
sation of heat or burning in the rectum. 



DYSENTERY. 127 

(3) TJie severe form. General nutrition is greatly im- 
paired. The patient becomes emaciated, pronounced gas- 
tric symptoms are present: anorexia, a bad taste in the 
mouth, often nausea, occasionally vomiting. As a rule, 
there is persistent diarrhoea, and the dejecta present a mu- 
cous or muco-sanguineous character. Colicky pains in the 
abdomen and pronounced tenesmus are present. In some 
cases, however, the diarrhoea alternates with short periods 
of constipation lasting two or three days. The patient 
usually feels very weak and is obliged to stay abed a great 
deal of the time. 

Course. — The course of acute dysentery is very indefinite. 
Sometimes the disease terminates in recovery in eight to 
fifteen days ; sometimes in one to three months ; sometimes 
again death occurs a few days after the commencement of 
the disease. Again, a case of dysentery may at first be mild, 
but later assume a dangerous character, and even terminate 
fatally. Intermissions and exacerbations are often encoun- 
tered in this disease. When dysentery becomes chronic 
its duration varies greatly, often depending upon the 
severity of each particular case. Thus, it may last five to 
six months or many years. Even in the chronic form 
recovery is not entirely impossible. 

Complications. — The course of the disease is occasionally 
modified by various complications. Peritonitis often re- 
sults from an extension of the ulcerative process from the 
intestinal wall to the peritoneum. Perforation of the 
intestine may occur in a similar way, and is observed 
principally in gangrenous dysentery. Sudden death is 
occasionally observed in such an event. In acute as well 
as in chronic dysentery severe hemorrhages from the bowel 
may take place. The loss of blood may be so great even 
as to cause death. Thrombosis of the femoral artery as 
well as of the venous sinuses of the brain has been observed 



128 DISEASES OF THE INTESTINES. 

by Laveran J as a complication of dysentery. A patient of 
mine with acute dysentery, apparently on the road to im- 
provement, suddenly one day developed a paralysis of the 
upper and lower right extremities. He later lost con- 
sciousness and died about forty -eight hours after the first 
signs of paralysis. Here most probably thrombosis of 
some brain vessels took place. 

The most frequent complication of dysentery is abscess 
of the liver. In the majority of instances it is observed 
in convalescence from acute dysenterj^ or during the evolu- 
tion of chronic dysentery. The symptoms of the forma- 
tion of an abscess in the liver are : fever of an irregular 
character, occasionally chills and pain in the hepatic region 
which may radiate to the right shoulder. The physical 
examination often reveals some enlargement of the liver. 
In the event of a liver abscess opening into the lungs, 
there is persistent cough and sometimes expectoration of a 
reddish-brown fluid containing amcebse. Abscess of the 
liver is more frequently encountered in tropical regions 
than here. The course of such an abscess is very irregular. 
Sometimes it progresses rapidly, at other times it shows 
periods of intermissions and exacerbations. The large 
abscesses of the liver, if not operated upon, usually termi- 
nate in death. Rarely recovery may follow the opening of 
the abscess into a neighboring organ. 

Diagnosis. — The diagnosis of acute dysentery is usualty 
very easy. The symptoms above described, being ordi- 
narily present, cannot fail to indicate the disease. The 
most reliable evidence is afforded by the character of the 
dejecta, the presence of mucus, an admixture of blood and 

1 Laveran: "De la phlebite, de la thrombose et des paralysies com me 
complications de la dysenteric" Archives de Medecine militaire, 

1885. 



DYSENTERY. 129 

pus corpuscles. Appendicitis is occasionally simulated by 
dysentery if the pains involve principally the appendicular 
region. Usually, however, it will be found that, besides 
the tenderness over the appendix, there are also similar 
areas of pain over other portions of the large bowel, espe- 
cially in the left iliac fossa. Besides, the character of the 
stool will help to reveal the true condition. Widal's reac- 
tion is not of great value in the recognition of this disease, 
for generally a positive agglutination reaction is not pres- 
ent before the second or third w T eek of the disease, and 
sometimes it appears still later. 

The diagnosis of chronic dysentery is usually somewhat 
more difficult. Repeated examinations of the faeces will, 
as a rule, reveal the presence of amoebae at one time or 
another and thus aid in discovering the disease. Many 
diseases of the rectum, as for instance proctitis, rectal 
polypus, and cancer, often present symptoms similar to 
those of chronic dysentery. A careful local examination^ 
however, will clear up the diagnosis without difficulty. 

Prognosis. — Dysentery must always be considered a 
quite serious disease. Even the mild form is at times 
liable to assume a dangerous character. On the whole 
dysentery must be regarded as a treacherous and insidi- 
ous malady. In general it must be said that cases of 
sporadic dysentery or of the epidemic form appearing in 
the cold and temperate zones take a much milder course 
and thus present a more favorable prognosis than does 
the endemic dysentery of hot climates. These remarks 
apply to both acute and chronic dysentery. 

Treatment of Acute Dysentery.— The patient must be kept 
abed and put on a diet consisting of liquid food (milk and 
strained barley water, bouillon, bouillon with egg, egg 
water, tea). Ipecacuanha has been found of great benefit 



130 DISEASES OF THE INTESTINES. 

in this disease. It may be given, according to Sodre, in 
the following combination : 

Powdered ipecacuanha 0.1 (gr. ij.) 

Powdered opium 0.02 (gr. i) 

Calomel 0.05 (gr. f) 

In capsules, one to be taken every two hours. 

In case the evacuations contain very small quantities of 
fecal matter, it is best to give a cathartic, as a large dose 
of castor oil (one to two tablespoonfuls) or sodium or mag- 
nesium sulphate one teaspoonful twice during the day. 
The purgative, however, should be administered only on 
the first or second day of the disease, and not be kept up 
for a long time. In order to allay the pains, hot poultices 
are applied over the abdomen and opium is administered. 
Thus, Dover's powder may be given in three-grain doses 
every two or three hours. This medicament may also be 
combined with salol, subnitrate of bismuth, tannigen, 
tannalbin, etc. The tenesmus, if severe, must be subdued 
by suppositories containing opium and belladonna, and by 
washing out the bowel with a quart of water containing a tea- 
spoonful of essence of peppermint, which can be done once 
or twice in twenty-four hours. Astringent solutions have 
been recommended as injections for the large bowel. They 
are not, however, of great benefit in acute dysentery. 

Serum Therapy. — The serum is obtained, according to 
Shiga, as follows : An agar culture of the bacillus dysen- 
terise which has been maintained at the incubator tem- 
perature for twenty-four hours is emulsified in normal 
saline solution and heated at 60° C. for one-half an hour. 
This mixture is then inoculated subcutaneously into horses 
in the usual manner, beginning with small doses, which 
are gradually increased in amount. The immunization 
can be more easily produced if immune serum is added to 



DYSENTERY. 131 

the emulsion of the ch-senteric bacilli, because abscesses 
which reduce the vitality of the animal are often produced 
at the site of inoculation when bacilli alone are employed. 
For the practical application of the serum, Shiga gives 
the following rules : 

1. In mild cases the serum is inoculated once in a dose 
of from 6 to 10 c.c. 

2. In cases of medium severity the serum is twice inoc- 
ulated in doses of 10 c.c. The interval is from six to ten 
hours. 

3. In severe cases the greatest quantities of serum are 
inoculated (about 60 c.c). The daily dose does not, how- 
ever, exceed 20 c.c. 

By serum treatment the disease in its first stages is 
quickly cured or markedly ameliorated. In advanced 
stages the effects produced are about as follows : The 
number of stools is markedly diminished, the tormina and 
tenesmus decrease, the blood in the stools diminishes or 
entirely disappears, the abdominal pains lessen, the fever 
ceases, the appetite increases, and the general condition is 
much improved. 

Besides the points just mentioned, the condition of the 
patient must be carefulty watched and every complication 
treated by itself. The high fever may necessitate the use 
of an antipyretic ; the weak action of the heart analeptic 
drugs, etc. As soon as the severe symptoms are allayed 
and the patient is on the way to recovery the diet can be 
cautiously increased. 

Treatment of Chronic Dysentery. — If the patient is living 
in an endemic centre of dysentery, it is best to send him to 
another climateo The hygienic surroundings of the patient 
should be carefully selected. The food should be well pre- 
pared. The patient should eat often, not too much at a 



132 DISEASES OF THE INTESTINES. 

time, and should avoid all coarse and highly seasoned sub- 
stances. Tarmigen gr. viii. three times daily or benzo- 
naphthol in the same dose, or subnitrate of bismuth gr. 
xxx. t.i.d., can be advantageously given. Sometimes these 
drugs are combined with codeine or opium. Here local 
remedies play a prominent part. Loesch was the first to 
recommend injections into the bowel of solution of quinine 
(1 : 5,000) ; tannic acid, nitrate of silver, permanganate of 
potassium have also been employed in clysters with good 
results. Harris very recently recommended the use of hy- 
drogen dioxide. The ordinary commercial hydrogen diox- 
ide is diluted from four to eight times with water and the 
solution injected. About a quart is injected twice daily for 
about a week and then gradually decreased. Harris has 
seen very good results from this mode of treatment. In 
cases in which there is an exacerbation of the disorder, the 
same mode of treatment may be required as in acute dys- 
entery. 



CHAPTER V. 

ULCEUS OF THE INTESTINES. 

1. DUODENAL ULCER. 

Synonyms. — Round duodenal ulcer; Ulcus duodeni pep- 
ticum (Leube). 

Definition. — A defect in the mucous membrane of the 
duodenum. 

Etiology. — The etiology of duodenal ulcer corresponds 
with that of gastric ulcer. It is undoubtedly caused, as in 
the stomach, by the action of the acid gastric juice upon 
the duodenal mucosa, the vitality and nutrition of which 
have been previously impaired. Such conditions occur as 
a result of circulatory derangements of various kinds. 
Thus, affections of the lungs and heart or of the liver, an 
atheromatous state of the duodenal artery may be the 
positive factors in disturbing the circulation of the mucous 
membrane. Burns of the skin are an etiological factor 
which, while not operative in gastric ulcer, is of great im- 
portance in duodenal ulcer. After extensive scaldings of 
the skin, quite often one or several duodenal ulcers ap- 
pear. According to Mayer 1 these ulcers develop from seven 
to fourteen days after the burn, very seldom much sooner. 
The primary cause of these ulcers is not yet known. The 
toxic theory which is the most plausible has been discussed 
above. 

Duodenal ulcer is much less frequent than gastric ulcer. 
1 Mayer; Annal. de la Soc. de Med. d' An vers, 1865. 



134 DISEASES OF THE INTESTINES. 

Willigk ! found it twice in sixteen hundred autopsies. Ac- 
cording to this writer; there are thirty-eight gastric ulcers 
to one duodenal ulcer. According to Starke, 2 however, 
the ratio is twelve to one. Kraus 3 found that the fre- 
quency of duodenal ulcers varies in different countries in 
a similar manner as does gastric ulcer, the northwestern 
part of Europe having the highest percentage, while it is 
but rarely met with in the eastern part. In Kraus' expe- 
rience duodenal ulcer most frequently occurs in persons 
between thirty and sixty years of age. Next in frequency 
comes the very early age (one to ten, and especially in- 
fancy). This is another point of difference between gas- 
tric and duodenal ulcers, for the former hardly ever occur 
in children. With regard to the distribution of duodenal 
ulcer among the sexes, Kraus found it much more preva- 
lent among the male than among the female sex, the rela- 
tion being ten to one. According to Lebert, 4 however, 
the proportion is only four to one. This again is another 
point of difference in the etiology of duodenal and gastric 
ulcers, for the latter, as is well known, are much more fre- 
quently encountered in women than in men (two to one). 

Morbid Anatomy. — A duodenal ulcer resembles in most 
particulars a gastric ulcer. It is a defect of the mucous 
membrane having an oblong and oval contour and extend- 
ing into the depth of the mucosa in form of a terrace or 
funnel. The ulcer presents an irregular shape only in 
those instances in which several ulcers have coalesced, thus 
forming one large defect. The size of the ulcer varies 
from that of a lentil up to that of a dollar. The margins 

1 Willigk : Prager Vierteljaliresschr., 1833. 

2 Starke : Deutsche Klinik, 1870. 

3 J. Kraus: "Das perforirende Geschwiir des Duodenum," Berlin, 
1865. 

4 Lebert : "Die Krankheiten des Mag-ens," 1878. 



DUODENAL ULCER. 135 

are usually smooth and overlapping, the latter being espe- 
cially the case in chronic affections. The base of the ulcer 
is formed either by thin layers of the remaining intestinal 
wall, or, if perforation has taken place, by adhesions with 
neighboring organs. 

Situation of the Ulcer. — Ordinarily the ulcer is found in 
the ascending or the upper horizontal part of the duodenum, 
much more rarely in the descending part, and only excep- 
tionally in the lower horizontal section. As a rule it is 
situated immediately behind the pyloric fold, rarely at 
some distant point. If the ulcer is situated in the descend- 
ing part of the duodenum, especially in the immediate 
neighborhood of the diverticulum Yateri, it may cause 
through cicatricial strictures important complications in- 
volving the pancreatic and biliary outlets. 

As a rule there is one duodenal ulcer, exceptionally there 
are two or four. In the latter instance the ulcers may be 
found in different stages of development : in the initial stage, 
in that of commencing cicatrization, or fully cicatrized. The 
cicatricial process may lead to manifold complications. A 
stenosis of the duodenum just behind the pylorus or at 
some distance may result, and create exactly the same dis- 
turbances of the stomach as are found in cicatricial stenosis 
of the pylorus itself. I had the opportunity of observing 
two cases of this kind. In both the diagnosis of a benign 
stricture of the pylorus had been made and the patients 
subjected to operation. At the laparotomy the stricture 
was found in the duodenum, in one case immediately behind 
the pylorus and in the other at some distance therefrom. 

Sometimes the ulcer progresses quickly and leads to per- 
foration into the peritoneal cavity. Death from shock or 
from diffuse peritonitis then occurs. If there is a slow 
extension of the ulcer, it often gives rise to circumscribed 



136 DISEASES OF THE INTESTINES. 

peritonitis, usually with adhesions to neighboring organs. 
If the ulcer perforates after adhesions have been formed, 
it usually leads to an encapsuled purulent peritonitis. The 
ulcerative process may occasionally extend to contiguous 
parts with the formation of ulcers in the liver, gall bladder, 
or other neighboring organs. The development of a cancer 
at the base of a duodenal ulcer has also been observed by 
Eichhorst ' and Ewald. 2 

Symptomatology. — Occasionally there may be no symp- 
toms whatever during life and the duodenal ulcer may not 
be discovered until at the autopsy. Sometimes there are 
no symptoms at first, then suddenly the disease manifests 
itself by a severe and dangerous hemorrhage or by a fatal 
perforation. In the majority of cases, however, there are 
pronounced manifestations during the existence of a duo- 
denal ulcer. Most frequently pains are present, usually 
to the right of the linea alba, extending up to the right 
parasternal line in the region below the liver. These pains 
usually appear from half an hour to two or three hours 
after meals ; as a rule they do not radiate to the back but 
rather somewhat downward in the abdominal cavity . While 
the pyloric region is often found slightly painful on press- 
ure, there is no circumscribed area in the epigastrium 
intensely painful on deep palpation as in ulcer of the 
stomach. In rare instances the pains are felt by the patient 
in the epigastric region, which may also show tenderness 
on pressure. Dyspeptic symptoms, as for instance loss of 
appetite, nausea, fulness in the epigastric region, are as a 
rule absent. Vomiting is likewise a rare occurrence in 
simple duodenal ulcer, which has not gone on to a partial 
stenosis of the intestinal lumen. 

1 Eichhorst : Zeitschr. f . klin. Medicin, Bd. 14, p. 522. 

2 C. A. Ewald : Berl. klin. Wochenschr. , 1886. 



DUODENAL ULCER. 137 

Hemorrhages as the consequence of an erosion of a more 
or less large blood-vessel, through the progressing necrotic 
process, occur in about thirty per cent of duodenal ulcers. 
The blood is frequently voided with the stools (melsena) 
which appear dark red or tarry. Occasionally, however, 
there may be vomiting of blood (hsematemesis), in connec- 
tion with the melsena or without it. If the hemorrhage is 
very great the patient may bleed to death. This, however, 
is rare ; as a rule the patients recuperate from the loss of 
blood in about the same time as they do from a gastric 
hemorrhage. 

Constipation is often present. The general condition of 
the patient is usually good and there may be no loss in 
flesh. 

Perforation is quite a frequent event in duodeual ulcer. 
The symptoms will differ according to whether perforation 
lias taken place before or after adhesions have been formed. 
In the former instance perforation leads to a general peri- 
tonitis, ending fatally in eighteen to thirty hours. Rarely 
the course is more protracted when the inflammatory proc- 
ess of the peritoneum has not assumed large dimensions 
and has become quickly localized through the formation of 
adhesions in the neighborhood. The perforation mani- 
fests itself by a sudden appearance of intense pains in the 
abdominal cavity, by the usual signs of a general collapse 
(cold extremities, very quick pulse), and by a swelling of 
the abdomen. The patient presents an expression of ex- 
treme anguish and maintains a rigid attitude often with 
the legs flexed, being afraid even to stir. The abdomen is 
painful to the slightest touch. Nausea and constant sin- 
gultus soon appear. Sometimes the patient is greatly 
tormented with vomiting. A few hours later, in addition 
to these symptoms, the area of liver dulness may be found 



138 DISEASES OF THE INTESTINES. 

absent in consequence of the escaped gas which has accumu- 
lated above its surface and has pressed it down. Dyspnoea 
and coma ultimately set in and the patient succumbs. 

If perforation has taken place after adhesions have been 
formed, the same complications occur as in ulcer of the 
stomach under similar conditions. The duodenal ulcer 
often heals and there is a complete disappearance of all the 
morbid symptoms. Sometimes the cicatrix leads to a stric- 
ture of the duodenal lumen and then gives rise to ischo- 
chymia. 

Course. — The duodenal ulcer has, as a rule, a very pro- 
tracted course. In some instances a perfect cure may be 
established without any ill consequences. In the majority, 
however, complications are common. Hemorrhages, ob- 
struction of the duodenal lumen in consequence of the 
stenosis and perforation are often observed. 

Diagnosis.— The diagnosis of a duodenal ulcer can be 
made with certaint3 r only in a very few instances. Most 
often only a probable diagnosis will be possible. A duo- 
denal ulcer can be diagnosed with certainty if the symp- 
toms of ulceration follow within a short period after exten- 
sive scalding of the skin has taken place. The sudden 
development of icterus in a case presenting symptoms of 
gastric ulcer speaks with a certain amount of probability 
for a duodenal ulcer if gall stones can be excluded. The 
points which indicate a probable location of the ulcer 
within the duodenum are the following: 1. The pains 
usually appear from half an hour to three hours after the 
ingestion of food and are situated most often to the right 
of the linea alba in the pyloric region. They never radiate 
to the back. 2. Eepeated attacks of melaena, either not as- 
sociated with hsematemesis or in which the latter was only 
slight compared with the melsena. 3. Most of the patients 



DUODENAL ULCER. 139 

are men presenting a healthy appearance. 4. Perforation 
is a frequent occurrence in duodenal ulcer, while it is very 
rare in the course of gastric ulcer. If all these points are 
found associated, then a probable diagnosis of duodenal 
ulcer may be made, otherwise it is uncertain. 

With regard to the differential diagnosis between ulcer 
of the stomach and that of the duodenum, Leube ] stated 
that in the latter the gastric contents show a normal degree 
of acidity, while in gastric ulcer, as a rule, hyperchlorhy- 
dria prevails. This point, however, is not of much value, 
for on the one hand cases of gastric ulcer are found with 
a lessened degree of secretion, and on the other hand 
duodenal ulcer may be attended with hyperchlorhydria. 
In the two cases of duodenal ulcers mentioned above which 
had been operated upon, the condition of the gastric juice in 
one was normal, while the other showed intense hyperchlor- 
hydria. The differential diagnosis between ulcer and can- 
cer of the duodenum is the same as that between ulcer and 
cancer of the stomach or pylorus. 

Prognosis. — The prognosis of duodenal ulcer is almost 
always quite serious, as complete recovery is very rare. 
Relapses after apparent perfect recovery often occur. The 
sequelae to which the cicatriziug process may give rise, 
namely, obstruction of the duodenal lumen, must also be 
taken into consideration, and the possibility of death from 
perforation should never be forgotten. Another danger 
lies in the formation of a cancerous growth on the base of 
the ulcer. 

Treatment. — On the whole the treatment must be con- 
ducted on the same line as that of ulcer of the stomach. 

1 Leube: von Ziemssen's "Handbuch der speciellen Pathologie und 
Therapie, " Bd. vii., Abth. 2. "Die Krankheiten des Magens und 
Darms, " Leipzig, 1876. 



140 DISEASES OF THE INTESTINES. 

In some cases the advisability of operative intervention 
must be considered. Cases in which a duodenal ulcer can 
be diagnosed with great probability and in which hemor- 
rhages have recurred several times may perhaps be sub- 
jected to a gastro-enterostomy during the period of com- 
parative euphoria. For by this procedure the duodenum 
is relieved of a great deal of irritation caused by the pas- 
sage of the chyme, and the ulcer is thus given a better 
chance to heal. In two instances of duodenal ulcer with 
periodically appearing large, almost fatal, hemorrhages, I 
had a prophylactic gastro-enterostomy performed in the 
interval, with perfect success. Cases in which the cicatrix 
has led to a partial stenosis of the duodenal lumen should 
certainly be operated upon, pyloroplasty or gastro-enter- 
ostomy being selected. 

2. EMBOLIC AND THROMBOTIC ULCERS. 

This group of ulcers resembles the duodenal ulcer in that 
disturbances of the circulation are the exciting causes. 
These ulcers are of very rare occurrence. Embolic ulcers 
were first described by Parenski. 1 They originate in con- 
sequence of emboli which are carried into the fine branches 
of the intestinal arteries, either from some abscess cavity 
or from a focus of atheroma or endarteritis. 

The pathological changes of the intestine after such an 
occurrence are slight if a very small vessel, a capillary or 
an arteriole, has been occluded. In case the embolus is of 
an infectious nature, infiltration and formation of pus soon 
develop, and the process may quickly penetrate down to 
the serosa and infect the peritoneal cavity. It may also 
rapidly reach the intestinal lumen and thus produce an 
ulcer. In the infectious cases the fatal issue often ensues 

1 Parenski : Wiener med. Jahrbticher, 1876, Heft 3. 



EMBOLIC AND THROMBOTIC ULCERS. 141 

so quickly that there is hardly time for a complete forma- 
tion of the ulcer. In such instances only the initial stages 
of the ulcerative process can be discovered. Fine nodules 
will be noticed in the intestinal wall originatiDg from the 
submucosa and consisting of accumulations of round cells 
in the centre of which are very small blood-vessels. 

The symptoms of these embolic ulcers are the same as 
those caused by other ulcerative processes of the intestines, 
namely, severe pain which may be of a colicky nature, 
tenderness on pressure over the abdomen, and diarrhoea 
with more or less bloody admixture. If these symptoms 
are present and embolic processes can be discovered in 
other organs, then the diagnosis of embolic ulcer of the 
intestine is probable. 

The clinical symptoms and the anatomical changes re- 
sulting from the obstruction of a very small blood-vessel of 
the intestines are comparatively slight, compared to those 
which rapidly appear if the embolus has entered the 
arteria mesaraica superior. This affection is extremely 
rare; only nineteen cases have been described in literature. 
The emboli which have been found in the arteria mesaraica 
superior itself or in its branches could be traced to the 
left heart or to the aorta, which was the seat of excres- 
cences due to endocarditis or atheroma. There is either 
a total obstruction of the entire mesaraic artery or several 
larger and numerous smaller branches of this vessel are 
occluded. The changes which frequently result after the 
embolus has excluded the organ from circulation are hem- 
orrhagic infarcts and necrosis with partial peritonitis. 
According to Litten, 1 after an occlusion of the arteria 
mesaraica superior or its branches, the intestine is deprived 

1 Litten : " Ueber die Folgen des Verschlusses der Arteria mesaraica. 
superior." Virchow's Arch., Bd. 63. 



142 DISEASES OF THE INTESTINES. 

of all arterial blood, there being no vicarious blood current 
from any anastomoses of these vessels. The arteria mesa- 
raica superior, although it forms anatomical anastomoses, 
acts functionally like a terminal artery . The reason of this 
is that the anastomosing vessels are of a very small calibre 
and pursue a very long course, and hence the mesenteric 
arteries are not able sufficiently to supply with blood the 
region deprived of its circulation. 

The pathological changes which appear after the occlusion 
of this artery consist of venous hyperemia, hemorrhagic 
extravasations, oedema, and necrosis. In that part of the 
mesentery and intestine which was supplied by this oc- 
cluded vessel, the smaller arteries branching off from the 
latter are contracted and empty, while the veins of the 
serosa and mesentery are overfilled with blood. The 
mucous membrane appears dark red ; the entire intestinal 
wall is ©edematous and swollen; small hemorrhages exist 
all over the mucous membrane and in the mesentery ; and 
the intestinal canal contains extravasated blood either fresh 
or tarry looking. If the process has lasted for some time, 
necrotic changes soon appear and the mucosa presents a 
dirty brownish-green appearance and may be wiped off 
from the other layers like a slimy coating. The serous 
layer may be the seat of inflammation not only over the 
involved intestinal segment, but also over other still healthy 
intestinal coils, the latter being agglutinated and covered 
with a deposit of fibrin. In the peritoneal cavity there 
may be a bloody fluid or a purulent exudation. 

The clinical symptoms of an embolus of the superior 
mesenteric artery have been best described by Gerhardt 1 

1 Gerhardt : " Embolie der Arteriae mesenteric^. " Wiirzburger med. 
Zeitschr., 1863, Bd. iv. 



EMBOLIC AND THROMBOTIC ULCERS. 143 

and Kussmaul.' They are not always alike, and two 
groups of cases may easily be discerned. In the one, being 
the larger, an intestinal hemorrhage is the feature most 
marked, in the other the affection presents the picture of 
intestinal occlusion with or without any signs of perito- 
nitis. As a rule the disease sets in suddenly with violent 
colicky pains involving the entire abdomen or some por- 
tion of it, usually in the neighborhood of the navel. 
Soon the pains grow diffused and there is an extreme ten- 
derness on pressure over the abdomen. Sometimes the 
pain is accompanied by vomiting ; in rare instances, how- 
ever, the pain may be entirely absent. Such a case has 
been mentioned by Xothnagel. Intestinal hemorrhage, 
which is the chief symptom, soon occurs. As a rule sev- 
eral bloody stools appear in succession, which have a dark, 
almost black, brown or tarry appearance and occasionally 
a very fetid odor. The blood of the hemorrhage, how- 
ever, is not always necessarily voided per rectum, for it 
may remain in the intestinal canal. The symptoms, how- 
ever, which characterize a profuse intestinal hemorrhage 
(falling of the body temperature and collapse) will never 
be missing. In the second group of cases there are merely 
signs of an acute intestinal occlusion; pains, constipation, 
and peritonitis being the only symptoms. 

The diagnosis of this affection can be made, according to 
Kussmaul and Gerhardt, in cases in which the source of 
the embolus can be determined. An intestinal hemorrhage 
occurs (for which no primary lesion exists), colicky pains 
of great violence and later a tympanitic swelling of the 
abdomen and exudations make their appearance. The 
diagnosis can be possibly made only if all the just men- 

1 Kussmaul: " Zur Embolie der Arteriae mesenteries. " Wurzburger 
mod. Zeitschr., 1864, Bd. v. 



144 DISEASES OF THE INTESTINES. 

tioned points exist. Otherwise, especially if the intestinal 
hemorrhage is missing, the diagnosis cannot be made 
during life. 

The prognosis of this affection is very grave. As a rule 
it ends fatally. It appears, however, according to Vir- 
chow, that in rare instances a recovery is possible after 
long illness, a collateral circulation having slowly devel- 
oped. 

With regard to treatment, there is no special indication 
for this affection. The symptoms will have to be treated 
as such. 

Embolus of the inferior mesaraic artery is a very rare oc- 
currence. Two cases have been described by Hegar l and 
Gerhardt. The prominent symptoms are violent colicky 
pains, tenesmus, and bloody stools. The mucous mem- 
brane of the small intestine remains normal, while that of 
the colon, S romanum, and rectum becomes intensely red, 
succulent, and contains effusions of blood here and there. 
Severe anatomical lesions of the intestines, however, are 
absent, for the circulation is quite quickly re-established 
through anastomosis with the superior mesenteric artery 
and with the rectal arteries of the hypogastric vessel. 

Similar to the lesions of the embolic process of the 
superior mesaraic artery are the consequences which result 
from a thrombus within the mesenteric veins or the portal 
vein. A few cases of this nature have recently been ob- 
served by Pilliet, 2 Grawitz, 3 and Eisenlohr. 4 The clin- 

1 Hegar: "Embolie der Lungenarterie und der Arteria mesaraica in- 
ferior." Virchow's Arch., Bd. 93. 

2 Pilliet: "Thromboses des veines mesaraiques. " Progres med., 
1890, No. 25. 

3 Grawitz : " Ein Fall von Embolie der Arteria mesaraica superior. " 
Virchow's Arch., Bd. 110. 

4 Eisenlohr : " Zur Thrombose der Mesenterialvenen. " Jahrbttcher 
der Hamburger Staatskrankenanstalten, 1890. 



AMYLOID ULCERS. 145 

ical picture of these cases is as follows : There appear sud- 
denly violent colicky pains in the abdomen. The latter 
swells up and grows intensely painful on pressure. Often 
vomiting is present, occasionally hsematemesis. There 
may be constipation or very frequent diarrhceal and bloody 
movements. Accompanying these symptoms there is al- 
ways collapse. The course is also a very rapid one, the 
fatal end appearing after two or three days. This affection 
is liable to occur in ads^anced pulmonary tuberculosis, in 
highly marasmic conditions like the malarial cachexia, then 
as a consequence of pressure of the portal vein, in cirrhosis 
and cancer of the liver. All abdominal neoplasms may 
likewise produce a thrombotic condition of the veins by 
pressure. The same may happen in chronic peritonitis by 
the formation of constricting cicatricial tissue. Similar 
processes also arise whenever the intestine experiences 
pressure or incarceration at a circumscribed spot. The 
venous circulation becomes obstructed by the pressure, 
while the arterial blood supply owing to its elastic walls 
remains undisturbed. In consequence of the lacking out- 
flow of the blood, hyperemia appears, then follow hem- 
orrhagic infarcts, and lastly necrosis. 

As the symptoms and treatment of the following classes 
of intestinal ulcers are identical, we shall discuss them 
together later on, after having first given the etiological and 
anatomical features of each separately. 

3. AMYLOID ULCERS. 

Amyloid processes within the intestine were first de- 
scribed by Virchow l in 1855. The amyloid changes start 

1 R. Virchow: "Ueber den Gang der amyloiden Degeneration." 
Virchow 's Arch., Bd. 8. 
10 



146 DISEASES OF THE INTESTINES. 

in the walls of the small blood-vessels (capillaries and the 
finest arteries, occasional^ also the veins) . 

At first the vessels of the mucosa alone are affected, but 
afterward the process may extend through the submucosa 
and even through the entire intestinal wall down to the 
serous layer. The amyloid degeneration may also involve 
the muscularis mucosae, or even the entire muscular layer 
of the intestinal walls. The amyloid degeneration of the 
blood-vessels makes them friable, thereby often leading to 
necrotic processes with the formation of small ulcers. 

Amyloid changes are found more often in the small intes- 
tine than in the large bowel. The mucous membrane of 
the affected part has a waxy and pale appearance. The 
villi are missing here and there. 

The diagnosis can be positively made by means of the 
characteristic color tests. A solution of iodine poured over 
the suspected area gives a brownish-red color which be- 
comes violet or blue after the addition of sulphuric acid ; 
a solution of methyl violet produces a bright pink color. 

We have reason to suspect amyloid processes within the 
intestine in conditions which are known to be often asso- 
ciated with this process, as tuberculosis, syphilis, leukae- 
mia. Especially is this true if amyloid degeneration is 
detected in other organs (spleen and liver) as shown by 
their enlargement, and besides there are signs of chronic 
diarrhoea and insufficient intestinal absorption. There are, 
however, no positive means of establishing the diagnosis 
of amyloid degeneration of the intestine during life. 

4. TUBERCULOUS ULCERS. 

Tuberculosis of the intestines is of very frequent occur- 
rence. While it usually appears in phthisical patients, 
there are also cases of an undoubted primary intestinal 



TUBERCULOUS ULCERS. 147 

tuberculosis. According to Frerichs, 1 a tuberculous affec- 
tion of the ileum is found in eighty per cent of the cases 
of chronic pulmonary phthisis. Bayle in 1810 was the first 
to observe the occurrence and frequency of tuberculous ul- 
cers of the intestine. The seat of these ulcers is princi- 
pally in the ileum, especially in its lower portion. They 
may extend from this point downward over the colon to the 
rectum or upward over the entire ileum, jejunum, and even 
the duodenum. 

The development of the ulcer takes place in the following 
way: In one of the solitary follicles a miliary tubercle 
forms by extensive accumulation of cells, the latter swell 
up; after a time a caseous degeneration appears in the 
centre and the swollen follicle bursts; thus a small pea- 
sized ulcer is formed. In the same way tuberculous proc- 
esses may develop in the agminated follicles and also lead 
to the formation of ulcers. But whereas Peyer's patches 
are equally affected in their entirety in typhoid fever and 
intestinal catarrh, in tuberculosis the infiltrations are con- 
fined only to several follicles of the group, while others be- 
longing to the same patch remain intact. 

The ulcsr enlarges either by spreading directly at the 
periphery or by the coalition of several defects. As a rule 
the extension of ulcers into the deeper layers proceeds in 
a line transversely to the intestinal lumen corresponding 
to the direction of the vessels supplying the bowels. Thus 
in the small intestine the ulcer spreads in a line parallel 
with the valvulae conniventes, and thus may form a circu- 
lar defect over the entire lumen of the intestine, trans- 
versely to its longitudinal axis (the so-called tuberculous 

1 E. Frerichs : "Beitrage zur Lehre von der Tuberculose, " Marburg, 
1882. 



1-A8 DISEASES OF THE INTESTINES. 

girdle ulcer). There exist, however, ulcers of an oblong 
or entirely irregular shape. With regard to the depth of 
the ulcer it usually penetrates to the muscularis and re- 
mains at a standstill there. Small tuberculous foci, how- 
ever, are often met within the latter, usually connected 
with the lacteals. Sometimes a destruction of the mus- 
cular layers is also present and the ulcer may advance 
down to the serosa and may even perforate into the peri- 
toneal cavity. 

The fully developed large tuberculous ulcer has an irreg- 
ular shape, and mostly a bright red margin, being partly 
smooth, partly overlapping, sometimes undermined. Its 
base is pultaceous, consisting partly of decomposed tissue, 
partly of swollen remnants of the mucosa. Tuberculous in- 
filtrations are noticeable here and there at the base as well 
as at the margin. The surroundings of the ulcer often 
show catarrhal changes. The serosa over it is usually in 
a state of chronic inflammation, being reddened, thick- 
ened, and surrounded with fibrinous exudations. Some- 
times there are agglutinations with other intestinal coils, 
the omentum, or other immediately adjacent organs. The 
frequency of these peritonitic adhesions explains why per- 
forations of tuberculous ulcers within the intestine are 
comparatively so rare. 

Tuberculous ulcers very rarely show a tendency to heal, 
the process as a rule progressing steadily and leading to 
the formation of new nodules in the neighborhood of the 
margin. In very few instances, however, cicatrization of 
the ulcers takes place. The latter, when occurring in ul- 
cers of girdle shape, may produce a stenosis of the intes- 
tinal lumen. 

Tuberculous ulcers are very rarely primary, that is to 



TUBERCULOUS ULCERS. ' 149 

say, developing in the intestines without a previous tuber- 
culous affection existing in other organs. In most instances 
they are secondary and are met with in patients who are 
in a more or less advanced stage of pulmonary tuberculosis. 
The ultimate cause of tuberculous processes in the intes- 
tine is Koch's tubercle bacillus. The latter may be car- 
ried into the intestinal canal with the sputum which 
phthisical patients swallow, or it may also, in rare in- 
stances, be ingested directly with the food. Thus, meat 
and milk of tuberculous cows may cause primary tubercu- 
losis of the intestine. This condition is specially frequent 
in infants on account of their being fed with milk either 
from phthisical nurses or tuberculous cows. 

5. SYPHILITIC ULCERS. 

Syphilitic ulcers of the intestines are quite rare. In the 
small intestine they are mostly met with in the new-born. 
Here the ulcers are found either singly or in great num- 
bers over the entire small intestine. They originate in the 
lymphatic apparatus of the mucosa and submucosa, first 
forming gummata within the intestinal walls, which after- 
ward undergo rupture. Syphilitic ulcers of the small in- 
testine have also been observed in adult life (Klebs, 1 Birch- 
Hirschfeld 2 ). 

Of greater clinical importance are the acquired syphi- 
litic ulcers which often occur principally in the lower 
part of the colon and the rectum, including the anus (most 
frequently the lower part of the rectum a few centimetres 
above the anus is affected). We may have primary ulcers 

1 Klebs: "Handbuch der pathologischen Anatomic" Berlin, 1868. 

2 Birch-Hirschfeld : "Lehrbuch der pathologischen Anatomie, " Leip- 
zig, 1887. 



150 DISEASES OF THE INTESTINES. 

of the rectum through direct infection after a preternatural 
coitus. These are observed principally in men and are 
located in the median line of the anus. They are character- 
ized by a hard base, sharp margins, and bacon-like appear- 
ance. We may also have secondary ulcers due to constitu- 
tional syphilis. Condylomata and gummata may undergo 
degenerative changes and form ulcers, which by their cica- 
trization very often give rise to the development of stric- 
tures of the rectum. The latter variety is much more fre- 
quently found in women than in men. Among two hundred 
and nineteen patients with constricting rectal ulcers 
Poelchen 1 found one hundred and ninety women. This 
author, however, correctly remarks that not all these ulcers 
resulting in stricture are due to syphilis. In a great many 
instances their origin is attributable to a gonorrhoeal affec- 
tion of the Bartholinian glands which ultimately through 
infection leads to destructive processes within the rectum. 
Some of these ulcers may also result from traumatic causes, 
such as the frequent use of clysters or hard fecal matter 
irritating the mucous membrane. 

6. TOXIC ULCERS. 

Under the term toxic ulcers of the intestine are under- 
stood defects which develop in consequence of abnormal 
(toxic) products contained in the blood. Thus intestinal 
ulcers occur in severe forms of nephritis, especially when 
they are complicated with ursemic symptoms. In leukaemia 
and scurvy such ulcers are also met with. Intestinal ulcers 
arising in cases of poisoning with mercury likewise belong 
to this group. The ulcerative process in all these cases is 

1 Poelchen : " Zur Aetiologie der stricturirenden Mastdarmge- 
schwure. " Virchow's Arch., Bd. 127. 



TOXIC ULCERS. 151 

best explained as due to necrosis in consequence of the 
altered condition of the blood. 

Symptomatology.— The symptoms which accompany ul- 
cers of the intestines vary greatly. In the following we 
shall enumerate all the symptoms which may be met with 
in these conditions. 

1. Diarrhoea. Frequent loose movements are often pres- 
ent, especially if the ulcer is situated in the lower part 
of the large bowel. Ulcerations of the small intestine, 
caecum, and the upper end of the large bowel do not cause 
diarrhoea, unless there is some other complicating affection 
(a catarrhal condition of the bowels or an amyloid state). 
But even if the ulcer is situated in the lower part of the 
colon, diarrhoea may be absent in rare instances, 

2. The occurrence of blood or pus in the dejecta. Blood- 
may be voided with the stools in consequence of a small 
hemorrhage of the ulcerated intestine. If there is no gas- 
tric ulcer, and other symptoms point toward intestinal ulcer,, 
the presence of blood will help to make the diagnosis more 
probable. But it is by no means a positive sign, for, on 
the one hand, an intestinal ulcer may exist without any 
hemorrhages, and, on the other hand, intestinal hemor- 
rhages may occur from other causes than ulcer. The 
presence of pus in the stools seems to have much greater 
importance. According to Nothnagel, real pus (numerous 
round cells) in the faeces is one of the most valuable signs 
of ulceration of the intestines. It is to be understood that 
pus may also be present in ulcerative processes accom- 
panying neoplasms of the intestines and in abscesses which 
open into the intestine. The latter two conditions will 
have to be excluded before we can infer the existence of an 
intestinal ulcer from this symptom. The amount of pus 



152 DISEASES OF THE INTESTINES. 

in true ulcerations of the intestines is, as a rule, very 
small, and it is necessary to examine the dejecta quite 
thoroughly in order to find it. "While the presence of pus 
is so important a symptom in intestinal ulcer, its absence 
by no means speaks against it. For there may be no for- 
mation of pus at the site of the ulcerative spot, or the pus 
may be changed to such a degree that it is no longer recog- 
nizable, especially if the ulcer is situated high up in the 
intestine. 

3. The existence of tubercle bacilli in the dejecta is of 
great importance in cases in which pulmonary tubercu- 
losis can be excluded, since they then show primary intes- 
tinal tuberculosis. The absence of the tubercle bacilli 
does not speak against the presence of ulcerative areas in 
the intestines, nor does their presence positively indicate a 
tuberculous affection of the intestine when pulmonary tuber- 
culosis exists, for these microbes are then usually derived 
from the sputa which have been swallowed and carried 
down with the passages. 

4. Pains. If pains exist in the abdomen in a more or 
less circumscribed spot for a long period of time, and 
if these pains are increased on pressure, they are prob- 
ably due to an ulcer in the intestines. The absence 
of this symptom, however, speaks in no way against an 
ulcer, nor is its presence an absolute positive symptom for 
ulcer. 

The general state of the system need not be disturbed, 
if the ulcers are only few in number and very small. If 
their number, however, is great and their size extensive, 
so that a large part of the intestinal tract is involved in the 
ulcerative process, then nutritive disturbances will manifest 
themselves and marked emaciation take place. 



INTESTINAL ULCERS. 153 

Diagnosis. — As may be seen from the description of the 
symptoms, the diagnosis of ulcer of the intestines is, as a 
rule, quite difficult. Their existence may be suspected 
whenever there is diarrhoea of a severe nature and more or 
less intense pain over a certain fixed region of the abdomen 
extending over a great period of time. A positive diag- 
nosis can be made only in the following instances : 

1. If necrotic pieces of the intestinal mucosa or pus 
appear in the stools (in the latter instance the perforation 
of an abscess into the intestine has to be excluded). 

2. The more or less frequent appearance of small amounts 
of blood quite changed in the stool, if ulcer of the stomach 
or vicarious bleeding can be excluded. 

3. Diarrhoea and the constant appearance of tubercle 
bacilli in the stools, when pulmonan tuberculosis can be 
excluded. This points to the presence of tuberculous proc- 
esses (ulcers) in the intestine. 

4. If the ulcers are situated in the lower part of the colon 
or rectum and are accessible to a direct visual examination. 

j-'he nature of the ulcers (whether catarrhal, tuberculous, 
syphilitic, or toxic) must be elucidated by a thorough 
knowledge of the history of the case and the results of an 
accurate examination of the patient. 

Prognosis. — The prognosis of intestinal ulcers will de- 
pend largely upon their number, size, and nature. A few 
small catarrhal ulcers will heal quickly without any further 
trouble. Amyloid ulcers hardly ever show a tendency to 
heal. Tuberculous ulcerations occasionally are amenable 
to treatment, still more so are the sj^philitic ulcers. Yery 
extensive ulcerations, no matter of what nature, are very 
dangerous to life. 

Treatment. — In the treatment of intestinal ulcers the 



154 DISEASES OF THE INTESTINES. 

etiological factors play the greatest part. Thus, in tu- 
berculous ulcers general hygienic rules will have to be 
observed. An out-of-door mode of living, and, if pos- 
sible, in the mountains, should be recommended. Guai- 
acol carbonate, creosote, ichthalbin are of value. In 
syphilitic ulcers general anti-syphilitic treatment should 
be instituted: inunctions with mercury, or injections of 
sublimate or calomel, or the administration of large doses 
of potassium iodide. In toxic ulcers (as those due to 
uraemia and mercurial poisoning) the treatment must be 
directed against the primary trouble. Besides the etio- 
logical therapy, intestinal ulcers require specific and 
symptomatic treatment. The treatment directed to the 
healing of the ulcers is very successful if the latter are situ- 
ated in the rectum or in the lower part of the colon, while 
this object can hardly be attained if they exist high up in the 
colon or in the small intestine. In the former instance the 
ulcers, if accessible to view, may be directly treated by the 
application of a strong solution of nitrate of silver or pro- 
targol. If not visible but situated in the colon, injections of 
a 0.2 to 1 per cent, solution of nitrate of silver or of tannic 
acid of the same strength into the bowels are of value. If 
the ulcers are situated in the small intestine, large doses 
of subnitrate of bismuth (1 to 2 gm. [gr. xv. to xxx.] three 
times a day) may be tried. The symptoms which accom- 
pany the ulcer and vary from time to time will have to be 
treated as such. Diarrhoea, hemorrhage, and pain must 
be combated with the customary remedies. 

Most patients should be kept abed for some time. The 
application of a hot-water bag or a wet pack over the 
abdomen is very beneficial. 

The diet should contain nourishing but easily digestible* 



INTESTINAL ULCERS. 155 

and non-irritating food. Thus milk, kurt^ss, matzoon, 
eggs beaten up in milk, soft-boiled eggs, farina, oat meal 
cooked in milk, mutton broth, chicken soup, scraped beef, 
calf's brain, sweetbreads, cacao, tea, and toast may be 
given, 



CHAPTER VI. 

NEOPLASMS OF THE INTESTINES. 
MALIGNANT GROWTHS. 

Cancer. 

Definition. — An epithelial neoplasm of the intestinal 
walls. 

Etiology. — The etiology of intestinal cancer, like that of 
cancerous disease of other organs, is still unknown. The 
traumatic theory (repeated irritation of one particular 
area) appears quite plausible with reference to this organ. 
As will be seen later, this malady occurs much more fre- 
quently in those parts of the bowels in which the passage 
of fecal matter is more apt to be retarded, and in conse- 
quence to cause irritation. 

With regard to sex, it is generally accepted that intes- 
tinal cancer occurs somewhat oftener in men than in women. 
With reference to age it is chiefly met with during the 
period from forty to sixty-five years. Cancer of the intes- 
tines is occasionally found also in young people, this hap- 
pening much more commonly than cancer of the stomach 
or of other organs. Nothnagel 2 has observed cancer of the 
caecum in a twelve-year-old boy, and Schoening 2 reports 
two cases of rectal cancer in girls seventeen years old. 

1 H. Nothnagel : " Die Erkrankungen des Darms und des Perito- 
neum, " Wien, 1898. 
8 Schoening: Deutsche Zeitschr. f. Chirurgie, Bd. xxii., 1885. 



MALIGNANT GROWTHS. 15- 

According to Maydl, J the total number of intestinal cancers 
occurring from the first to the thirtieth year amounts to 
one-seventh of the entire number of cases. 

Location. — With regard to location the frequency of the 
affection in the different portions of the bowel varies. The 
frequency gradually increases the lower down the growth 
is situated, beginning with the jejunum and ending with 
the rectum. Among one hundred and sixty autopsies on 
cases of cancer of the different organs, Maydl found in one 
hundred cancerous disease of the bowels. In one hundred 
and ten autopsies of patients suffering from intestinal 
cancer, Bryant 2 found the neoplasm located six times 
within the small intestine, seven times in the csecal and ileo- 
cecal regions, nineteen times in the transverse colon, includ- 
ing the hepatic and splenic flexures, seventy-eight times in 
the sigmoid flexure and rectum. Maydl gives the follow- 
ing locations of the tumor in one hundred autopsies : Two 
in the duodenum, four in the ileum (none in the jejunum), 
forty-six in the large bowel (in the vermiform process, one; 
caecum, nine; ascending colon, six; colon seventeen; sig- 
moid flexure, thirteen), and forty-eight in the rectum. As 
regards cases observed during life, Maydl gives the follow- 
ing figures : During twelve years there were in the Wiener 
Allgemeines Krankenhaus 246,827 patients. Among these 
there were 6,287 patients with cancer. Among the latter 
there were 254 cases of cancer of the bowels, and in 224 of 
these the neoplasm was in the rectum. This certainly shows 
the great predilection of intestinal cancer for the rectum. 

Intestinal cancers are almost always primary. It is 
exceptional for cancer of the bowels to develop by way of 
metastasis. It is obvious, however, that cancer in this. 

1 Maydl : " Ueber den Darmkrebs, " Wien, 1883. 

* Joseph D. Bryant : Annals of Surgery, February, 1893. 



158 DISEASES OF THE INTESTINES. 

region may develop secondarily as a result of direct exten- 
sion of the cancerous process from a contiguous organ. 
This often occurs in cancer of the stomach, gall bladder, 
or pancreas. Intestinal cancer often gives rise to metasta- 
ses in other organs. According to Muller, 1 these are more 
frequently met with in cancer of the small intestine than 
in that of the large bowel. The lymphatic glands are also 
often secondarily affected. Those in the neighborhood of 
the neoplasm show a greater tendency to become cancer- 
ous than those farther off. 

Morbid Anatomy. — All varieties of cancer are found in 
the intestines. Most frequently, however, the cylindrical 
epithelial-celled carcinoma, having a glandular structure 
(adeno-carcinoma), is encountered. The latter takes its 
origin in the epithelial cells of the follicles of Lieberkuehn. 
Colloid carcinoma is quite often found in the rectum, while 
melano-carcinoma is here quite rare. Occasionally the 
pavement-celled carcinoma (epithelioma cancroid) is met 
with, especially in the lower part of the rectum, starting 
principally from the anus. It often involves the perineum 
and the vagina. 

The neoplasm varies in consistency according as connec- 
tive tissue or cells predominate. If the former is the prin- 
cipal element, then the tumor presents a hard consistency 
(as hard as cartilage) and is termed scirrhus. In case the 
latter are more abundant, then it is less firm, occasionally 
soft and succulent. The colloid cancer as a rule contains 
a brownish, somewhat viscid fluid. The scirrhus shows a 
greater tendency toward partial necrosis in its central part. 
It often forms a carcinomatous ulcer. 

The primary intestinal cancer frequently shows a ten- 

2 Max Muller : "Beitrage zur Kenntniss der Metastasenbildung ma- 
ligner Tumoren. " Inaugural-Dissertation, Bern, 1892. 



MALIGNANT GROWTHS. 159 

dency to extend in a circular direction perpendicularly to 
the lumen of the bowel. Stenosis of the intestinal canal 
is very often the result of this circumstance. In case the 
stricture is of marked degree, the intestine above the stric- 
tured spot becomes greatly distended through stagnating 
fecal matter and gas. The bowels working hard to over- 
come the obstacle show thickened walls due to hypertrophy 
of the muscles. The irritating and stagnating contents in 
the dilated part of the intestine give rise to catarrhal in- 
flammation and also to ulcers. If the stenosis has become 
still more pronounced, the dilatation of the intestine above 
it may be so excessive that a rupture of its walls ultimately 
occurs. Below the stricture the intestinal wall appears 
thinner, and if the stricture is so narrow that no contents 
pass downward, it appears empty and contracted. Occa- 
sionally the neoplasm constricting the intestinal lumen 
begins to break down and ulcerate, and this partly removes 
the occlusion of the intestinal canal. This, however, does 
not last long, for as a rule the cancer shows a tendency to 
grow again and to fill up the defect. Thus the free lumen 
of the bowel is very soon again occluded. 

This partial necrotic process will also often cause more 
or less hemorrhage through erosion of the smaller blood- 
vessels. In case a larger artery or vein opens, a severe 
hemorrhage with fatal issue may result. 

Cancer of the bowels often involves, besides the mucosa 
and submucosa, the muscularis and even the serosa. In 
the latter event perforation occurs in rare instances before 
adhesions have had time to form, and may result in fatal 
general peritonitis. In most instances, however, adhe- 
sions have formed around the involved area, and thus the 
perforation causes merely a circumscribed peritonitis. 
Even without the occurrence of perforation the cancer may 



160 DISEASES OF THE INTESTINES. 

progress from the serous layer to the peritoneum and lead 
to a carcinomatous peritonitis, which is often accompanied 
by a hemorrhagic exudation. Another series of grave 
complications is caused by the extension of the cancerous 
process to a neighboring organ which has previously be- 
come agglutinated to the bowel. The process of disinte- 
gration in the cancerous growth then often establishes an ab- 
normal communication between the bowel and other organs. 
Thus fistulous openings may occur between colon and 
stomach, between rectum and bladder, between rectum and 
vagina, between rectum and uterus, between large and 
small bowels, or a direct fistulous opening may form from 
the bowel through the abdominal wall. 

Symptomatology .—Cancer of the bowels develops quite 
slowly and insidiously, and in most instances at the begin- 
ning gives rise to hardly any symptoms at all. For this 
reason it can never be detected at this time; later, how- 
ever, general and local symptoms manifest themselves. 
While the general symptoms are common to all cancers of 
the small and large bowels, the local symptoms will differ 
according to the location of the tumor, and it will therefore 
be necessary to consider the different portions of the intes- 
tinal tract separately. 

A. General Symptoms.— The general symptoms of cancer 
of the bowels are those found in malignant growths of other 
organs. Of these anaemia and cachexia are the most impor- 
tant. Usually both are present at the same time. Some- 
times one is more pronounced than the other. In some in- 
stances a general weakness, pallor, and emaciation are the 
first indications of a severe affection. There may be as yet 
no local symptoms whatever or a very slight degree of con- 
stipation and scarcely noticeable sensation of discomfort in 
the abdomen. Loss of appetite and slight dyspeptic symp- 



MALIGNANT GROWTHS. 161 

toms are often encountered. Fever is occasionally met with, 
which is clue to a suppurative process and absorption of 
pyogenic matter into the blood. The neoplasm often gives 
rise to disturbances in neighboring organs by constricting 
or dragging upon them. Thus radiating pains from com- 
pression of nerves may arise ami in the same manner dis- 
turbances of circulation. (Edema of the lower extremities 
is often encountered, which after lasting for weeks and 
months may occasionally disappear shortly before death. 

Symptoms of chronic intestinal obstruction are often pres- 
ent. They develop either gradually, the constipation in- 
creasing more and more, or they may appear more abruptly. 
The bowels, while formerly more or less regular, suddenly 
cease to move, and even strong cathartics are of no avail. 

The clinical features of cancerous obstruction of the 
bowels are not different from stenosis of the intestine caused 
by other processes, which are described in Chapter IX. 
Such a sudden attack of obstruction of the bowel may ter- 
minate fatally in a few days ; sometimes, however, after a 
total occlusion of the bowels, life continues much longer. 
Thus fecal retention of forty -four clays' duration, without 
even fecal vomiting, is mentioned by Heusgen, 1 and an- 
other case of eighty-eight days' duration has been reported 
by Cooper-Forster. 2 Diarrhoea is frequently present in 
cancer of the bowels. This often serves partly to overcome 
the beginning obstruction of the intestinal lumen. In some 
cases diarrhoea alternates with constipation. In the latter 
instance the stools often bear signs of having passed a 
strictured spot. They may appear in the shape of a tape 
or in the form of small, hard balls. These characteristics 
of the evacuation are, however, by no means a positive 

1 Heusgen : Deutsche med. Wochenschr. , 1877. 

2 Cooper-Forster : Medical Times and Gazette, September, 1867. 

11 



162 DISEASES OF THE INTESTINES. 

proof of a real stricture, for they are also met with in 
merely neurotic conditions. The stools often contain an 
admixture of mucus, blood, or pus. In case the progress 
of the necrosis of the neoplasm is pronounced, the stools 
during that period have a very offensive, almost unbear- 
able odor. In rare instances particles of tumor may be 
discovered in the dejecta, which show under the micro- 
scope the exact nature of the neoplasm. If these particles 
are of a large size (cherry or walnut) they will be easily 
discovered in the stools ; but if they are minute, a thor- 
ough examination of the fecal matter will be necessary in 
order to find them. Washing out of the bowels will often 
be helpful to discover such minute pieces of the growth, 
in case the latter is situated in the colon. 

While all of the above symptoms are of great value, they 
are unimportant compared with the physical signs of a 
tumor. Its presence in a doubtful case in most instances 
helps to clear up the diagnosis. The tumor is often easily 
palpable and bears the general characteristics of a cancer- 
ous growth. It is hard and presents an uneven nodular 
surface. Its size varies greatly, being often that of a wal- 
nut and occasionally that of an apple or still larger. In 
the latter instance the mere inspection of the abdomen may 
already show the presence of the tumor. In autopsies the 
neoplasm is frequently found much smaller than it ap- 
peared to be during life. The cause of this is the hyper- 
trophy which occurs in the walls of the bowel above the 
tumor, together with the accumulation of fecal matter at 
the same place. The tumor is usually situated in the 
lower half of the abdomen, principally in the left iliac re- 
gion, not only because this part of the intestine is so often 
affected, but also because a neoplasm of other parts of the 
bowels, if not fixed by adhesions, is as a rule dragged down 



MALIGNANT GROWTHS. 163 

by its own weight into this region. Intestinal neoplasms 
as a rule show a high degree of mobility. Often they can 
be moved with the hand in all directions in the abdominal 
cavity. The only exceptions to this rule are tumors of the 
duodenum, the sigmoid flexure, and the caecum, which are 
more or less fixed. 

With regard to the detection of the tumor a thorough 
palpation of the abdomen (if the abdominal walls are very 
rigid, under ether or chloroform narcosis) is necessary. A 
digital examination of the rectum, and, in women, of both 
rectum and vagina, will in most instances be required. A 
bimanual examination will also be found useful. In case 
the affected area in the rectum is not accessible to digital 
examination, inspection of this organ and in some instances 
a manual examination under anesthesia with the whole 
hand must be resorted to. 

When the disease is fully developed, peritonitis (either 
circumscribed or general) often appears as a complication. 
It may be simply caused by the inflammatory processes 
accompanying the neoplasm or be of a real cancerous na- 
ture. While at first it is impossible to differentiate these 
two conditions, later on it is as a rule not difficult to deter- 
mine which of the two is present. The discovery of a 
hemorrhagic exudation and of a few nodules under the 
abdominal wall will indicate that a cancerous affection of 
the peritoneum is present. An acute perforation peritoni- 
tis is much more rare and leads to shock and sudden death, 
or in the presence of adhesions to grave complications in 
consequence of fecal abscesses. If the perforation occurs 
into adherent neighboring organs, new communications 
may be formed between them and the intestine ; they ag- 
gravate the condition and are of great clinical importance. 
The following communications are frequently met with : 



164 DISEASES OF THE INTESTINES. 

1. Fistula between stomach and colon. The fistulous 
opening may freely communicate with both cavities or only 
in one direction on account of the formation of a valve. 
If the passage has the direction from the stomach into the 
colon, symptoms of lientery develop, and undigested and 
unchanged foods, as for instance pieces of meat, potatoes, 
spinach, and the like, appear in more or less large quanti- 
ties in the stools ; often diarrhoea manifests itself shortly 
after a meal and examination of the evacuation shows 
numerous particles of food from the last meal. Lavage 
of the stomach performed in such a case will often show 
that the liquid has escajjed from the stomach in consider- 
able quantity and may occasionally be voided by the rec- 
tum. The admixture of some coloring matter to the water 
used for lavage will facilitate the recognition of this condi- 
tion. If the communication has a direction in the oppo- 
site way, namely, from the colon into the stomach, there 
will be an appearance of fecal matter in the latter. In 
that event the gastric contents always contain decomposed 
and fetid material, and vomiting of fecal matter is fre- 
quently the result. Inflating the colon with air will often 
cause a filling up of the stomach with this gas, and again 
irrigation of the bowel with water (either clear or stained) 
will be followed by its appearance in the stomach, which 
,may be easily discovered by introducing a tube into this 
organ and evacuating the gastric contents. If the fistulous 
opening has a free communication in both directions, then 
symptoms of lientery and fecal vomiting may be present 
at the same time or they may appear alternately. 

2. In case of a communication between rectum and blad- 
der, small particles of fecal matter and gas appear in the 
latter organ and may be voided through the urethra. They 
give rise to a putrid cystitis. Occasionally urine may pass 



MALIGNANT GROWTHS. 105 

from the bladder into the rectum arid be discharged with 
the stools. The recognition of the latter condition is, 
however, more difficult. 

3. Communications behveen the rectum and uterus or 
vagina are also met with and give rise to the passage of 
fecal matter through these organs. 

4. A fistulous opening may exist between the bowel and 
the abdominal ivall. This fistula may discharge externally 
a putrid secretion having a fetid odor and containing par- 
ticles of fecal matter or chyle, depending upon its location, 
whether in the large or small intestine. 

All these fistulous communications appear as a rule in 
the last stages of the disease. They are, however, by no 
means characteristic of cancer of the intestine, for they 
may also, but very rarely, develop in consequence of other 
ulcerative processes in the bowel (tubercles). Again they 
may be a result of a cancerous growth in the stomach in- 
volving secondarily the intestinal tract. 

The urine does not show anything characteristic of can- 
cer. However, it often contains large amounts of indican; 
acetone and diacetic acid have also been occasionally met 
with. 

B. Symptoms Due to the Location of the Neoplasm. — (a) 
Cancer of the duodenum. In the duodenum the neoplasm 
almost always causes gastric symptoms similar in nature 
to those of cancer of the pylorus. Thus anorexia, pains, 
vomiting, and dilatation of the stomach will be the pre- 
dominating features. If the tumor is situated near the 
pylorus in the superior horizontal portion of the duode- 
num it will be quite movable, and a differential diagnosis 
between cancer of the pylorus and that of the beginning of 
the duodenum will hardly ever be possible during life. In 
case the neoplasm is situated in the descending part of the 



166 DISEASES OF THE INTESTINES. 

duodenum, in the immediate neighborhood of Vater's 
papilla, icterus is often encountered. In such cases the 
initial symptoms may be jaundice and sometimes chills. 
The icterus may remain stationary or vary in intensity 
from time to time according to the degree of the obstruc- 
tion of the duct caused by the neoplasm. Ulceration of the 
tumor may for a while open a passage for the bile and the 
jaundice may then temporarily disappear. If the cancer 
is located below Yater's papilla, especially in the inferior 
horizontal part, the gastric contents will frequently show 
the presence of a large amount of bile. In the latter two 
instances the tumor, if accessible to palpation, is not mov- 
able. On account of its deep situation it can frequently 
not be discovered. 

(b) Cancer of the small intestine. According to the re- 
gion in which the neoplasm is situated, whether at the 
beginning of the jejunum or in the lower parts of the 
ileum, gastric or intestinal symptoms will predominate. 
There may be anorexia and vomiting, or, on the other 
hand, good appetite and apparently good stomach diges- 
tion, but obstinate constipation. The tumor is often acces- 
sible to palpation, and is as a rule very movable. 

(c) Cancer of the large bowel. Pains are frequently en- 
countered at a localized spot in the region of the large 
bowel. They may exist before a tumor can be palpated 
and may be felt either in its immediate neighborhood or 
in almost exactly opposite portions of the colon. Thus 
cancer of the caecum may give rise to pain in the sigmoid 
flexure, and vice versa. These pains are rarely severe ; as 
a rule they consist merely in a sensation of discomfort or 
in a feeling of tension. Besides these uncomfortable sen- 
sations of a more or less permanent nature, there may be 
more or less frequent attacks of colic. In the latter in- 



MALIGNANT GROWTHS. 167 

stance there may be violent excruciating pains in the ab- 
domen, which may be relieved after passing of flatus or 
after a diarrhoeal movement. The attacks of colic are fre- 
quently caused by the commencing obstruction of the in- 
testine, and therefore become gradually aggravated in na- 
ture. They may lead at last to a total obstruction and be 
the immediate cause of death. Constipation is one of the 
foremost symptoms of a neoplasm of the large bowel. It 
is encountered in the great majority of cases; in some in- 
stances it forms the first symptoms of the disease ; at first 
it may be slight in nature, but becomes steadily more ob- 
stinate. Ten or twenty days may pass without a sponta- 
neous evacuation, and even cathartics are very slow in their 
action. The constipation as a rule is accompanied by the 
usual symptoms resulting from it, tension and fulness in 
the abdomen, poor appetite, occasionally pains. The con- 
stipation may at times disappear and give place to a pe- 
riod of diarrhoea. In some instances diarrhoeal evacu- 
ations may exist for many weeks, and they may be the 
predominating feature of the disease. 

(d) Cancer of the rectum. The symptoms met with in 
cancer of the rectum resemble more or less those of a neo- 
plasm of the upper portion of the large bowel. Here, how- 
ever, the diagnosis can be made with greater ease and cer- 
tainty. In most instances rectal cancer can be discovered 
by a digital examination of the rectum. By means of the 
latter we may discover a mass lying right beneath the mu- 
cous membrane of the rectum, over which the mucosa can 
be slightly moved or not at all if it is adherent. The sur- 
face may feel uneven and somewhat hard. Sometimes the 
finger encounters a constriction through which it cannot 
easily pass; the tissues here present the same character- 
istics as just described. Occasionally an ulcerated area 



168 DISEASES OF THE INTESTINES. 

can be discovered on the surface of the neoplasm. In can- 
cer of the rectum situated high up (not accessible to digital 
examination), several clinicians have advised examination 
with the whole hand passed through the rectum. This, 
however, can be done only under chloroform narcosis and 
is not free from danger. Such an examination may in rare 
instances cause rupture of the intestinal wall as stated by 
Yolkmann. 1 Inspection of the rectum by means of Kelty's 
speculum can be easily performed and aids us in discover- 
ing a neoplasm situated quite high up in the rectum, even 
if not accessible to digital examination. The latter instru- 
ment may also be used in neoplasms of the lowest part of 
the bowel, although its use here is not of much impor- 
tance, as the palpating finger gives us enough certainty in 
making the diagnosis. 

Cancer of the rectum is as a rule accompanied by severer 
pains than that of the large bowel. These as a rule are 
local in character. They often radiate toward the caecum 
and the lower lumbar region, toward the bladder and geni- 
tal organs, and sometimes in the direction of the sciatic 
nerves. In case the neoplasm involves the anus, there is 
an exacerbation of the pain at each evacuation. Tenesmus 
is constantly present in the latter instance. If such a neo- 
plasm of the lower parts of the rectum becomes ulcerated, 
the tortures of the afflicted person can hardly be described. 
The patient as a rule is afraid of having an evacuation, and 
tries to keep it back as long as possible. At last there is 
a movement containing fecal matter, mucus, blood, and 
sometimes pus, under most excruciating pains. 

Leube has directed attention to the fact that hemor- 
rhoids are frequently associated with the neoplasm of the 

1 Volkmann : "Ueber den Mastdarmkrebs. " Volkmann's Sammlung 
klin. Vortraege, No. 131. 



MALIGNANT GROWTHS. 1(39 

rectum. This is of importance, as it shows that the pres- 
ence of hemorrhoids should not lead one to abstain from 
digital rectal examination. If a patienfe has complained of 
constipation for a short period (a few months) and hemor- 
rhoids have developed during this time, the latter are 
rather indicative of a more serious condition, and a digital 
examination of the rectum should always be undertaken 
under such circumstances. 

Course. — An uncomplicated intestinal cancer may last 
for years. Frequently, however, the time is much shorter. 
Many complications are liable to occur— hemorrhages, per- 
foration peritonitis, rupture of the intestines, ileus, auto- 
intoxication, extension of the cancer to other organs, and 
metastases. On account of these many possibilities the 
life of the patient may be shortened, and it is hardly pos- 
sible to foresee its duration. In some instances a condi- 
tion of coma (coma carcinomatosum) appears quite early. 
It is generally assumed that the latter is due to auto-intoxi- 
cation, either by the products of decomposition of the in- 
testinal contents or by the toxins of the cancer. Ewald in 
such a case succeeded in isolating a body from the urine 
belonging to the group of diamins. In cancer of the 
duodenum the general nutrition suffers very early and ex- 
pensively, and for this reason the duration of life is short. 
In cancer of the rectum nutrition is well maintained for a 
long period, and for this reason the duration of life in the 
absence of complications is quite long (about four years). 
In case anaemia of a high degree supervenes, a marasmic 
thrombosis may develop and the patient may die in conse- 
quence of an embolus of the lungs. If intestinal cancer is 
unattended with complications, death often results in con- 
sequence of general exhaustion. 

Diagnosis. — The diagnosis of intestinal cancer can be 



170 DISEASES OF THE INTESTINES. 

made with certainty in the following instances : 1. If by 
abdominal or rectal palpation a tumor can be detected 
which is situated in the small or large bowel, and accom- 
panied by symptoms of cachexia and disturbances of defe- 
cation. 2. The presence of a tumor as just described, and 
the discovery of small particles of the neoplasm in the 
evacuation giving microscopically the appearance of a can- 
cerous growth. 3. Gradually increasing disturbances of 
the bowel for a few months in a heretofore healthy person, 
accompanied by cachexia and symptoms of a beginning or 
already developed stricture of the bowels and the jjresence 
of a small particle of growth in the stools, giving as above 
microscopically the picture of cancer. 

If there is no tumor and if nothing cancerous is found 
in the stools, the diagnosis can never be made with cer- 
tainty. A probable diagnosis of intestinal cancer will 
have to be made if cachexia is present, together with 
symptoms of gradually developing intestinal disturbances, 
indicating the beginning of an obstruction of the bowel, in 
a middle-aged or elderly person who has been well up to a 
few months before. 

Prognosis. — The prognosis of intestinal cancer is always, 
unfavorable. Unless an early operation and total ex- 
cision of the growth is resorted to, a fatal issue is sure to 
follow, although the exact duration of life can hardly be 
predicted, the latter depending upon subsequent complica- 
tions. 

Treatment. — A cure is possible only by a total and thor- 
ough removal of the growth. We must therefore always 
endeavor to make the diagnosis as early as possible and 
advise an immediate operation whenever feasible. Cancer 
of the rectum can be recognized quite early and resection 
of the neoplasm is here followed by brilliant results. If 



MALIGNANT GROWTHS. 171 

the tumor is located farther up iu the large bowel or in 
the small intestine, then the results of an operation are not 
so promising, for here the recognition of the growth is pos- 
sible only at an advanced period, and by that time often 
adhesions with other organs and cancerous infection of the 
glands have already taken place. Excision of the tumor 
and resection of the intestine in the neighborhood of the 
neoplasm with an end-to-end anastomosis should be prac- 
tised whenever feasible. In case, however, total resection 
is impossible, an entero-enterostomy or enter o-colostomy, 
or if the cancer is situated in the rectum, a colostomy (ar- 
tificial anus) will be of benefit. These operations are pal- 
liative in nature and prolong life, at the same time making 
it more comfortable. They are intended to allay the symp- 
toms of obstruction and to carry the fecal matter over a 
new route, not passing through and thus not irritating the 
cancerous area. In some instances of inoperable cancer of 
the rectum curettage followed by the application of the 
thermo-cautery is of benefit for a short period. 

Aside from these surgical means the treatment should 
be symptomatic. The diet should consist of foods con- 
taining plenty of nourishment but very little indigestible 
residue, thus forming only a small quantity of fecal mat- 
ter. If there is stagnation of the intestinal contents, 
cathartics will have to be given in order to liquefy the 
fecal matter. This can be done by means of castor oil, 
rhubarb, magnesium sulphate, and so on. If the neoplasm 
is located in the large bowel, irrigations with warm oil or 
water are preferable. The pains should be allayed by 
means of warm baths and cataplasms, but if these fail, 
by narcotic remedies, such as morphine, opium, codeine, 
or belladonna; suppositories being here most suitable. 
Eventual complications should be treated as such. 



172 DISEASES OF THE INTESTINES, 

Sarcoma and Lympho- Sarcoma. 

Sarcoma of the intestines is a much rarer affection than 
cancer. According to Kundrat, 1 in the Wiener Allgemeine 
Krankenhaus between the years 1882 to 1893 there were 
2,125 autopsies on cases of cancer. Of this number 243 
were cancers of the intestines. In the same period of time 
there were 274 necropsies on patients with sarcoma, of 
which 3 were located in the intestines. Among 61 lympho- 
sarcomata 9 were in the intestines. E. Libman 2 has re- 
cently published a number of personal cases of sarcoma of 
the small intestine. He is of the opinion that this affection 
is not so rare as is generally believed. On the whole the 
symptomatology of these malignant neoplasms coincides 
with that of cancer of the intestines. There are, however, 
a. few points in which they differ from intestinal cancer. 
While carcinoma is most frequently found in the lower 
portions of the large bowel, sarcoma shows a greater predi- 
lection for the small intestine and the upper portion of the 
large bowel. Thus, according to Nothnagel, among 9 cases 
of sarcoma of the intestines 1 was located in the duode- 
num, 3 in the jejunum, 3 in the ileum, and 2 in the caecum. 

Sarcoma of the intestines shows very rapid progress, 
and metastases in other organs are very early found. The 
duration of life is much shorter than in cancer, being in 
most cases about but nine months. There is only one in- 
stance mentioned in literature in which a patient lived one 
and three-quarter years after the first appearance of symp- 
toms. Symptoms of obstruction which are so frequently 

1 Kundrat: Gerliardt's " Handbuch der Kinderkrankheiten," Bd. iv., 
2te Abtheilung, Tubingen, 1880. 

' 2 E. Libman: "Ueber Dunudarmsarkome." Grenzgebiete der Medi- 
,zin und Chirurgie, Bd. vii., Heft 4 and 5, 1901. 



BENIGN TUMORS. 173 

found in cancer of the intestines are very rarely if ever met 
with in sarcoma. The tumor as a rule extends over a large 
part of the intestines, but does not occlude the canal. 
Cachexia and anaemia belong to the early symptoms, and 
are much more pronounced than in cancer. The progno- 
sis of this form of tumor of the intestines is absolutely 
fatal. Even in cases in which an operation is performed 
quite early, it is as a rule not of much benefit on account 
of the numerous metastases which develop so early ; aud 
on this account Madelung ! even hesitates to advise surgi- 
cal interference. 

BENIGN TUMORS OF THE INTESTINES. 

Of the benignant neoplasms the following forms are 
occasionally met with in the intestines : adenoma, fibro- 
ma, lipoma, rayonia, angioma, and cyst. These growths 
are termed polypi if they have a pedicle. Occasionally 
they have a large base and form only a small prominence 
over the surface. The polypi are usually of small size, 
that of a cherry or plum ; rarely they are larger, pear-sized 
or greater still. As a rule they are covered with normal 
mucous membrane. Although they are found almost every- 
where in the intestinal tract, they occur most frequently in 
the rectum (according to Rosenheim in eighty per cent). 

Among the benign tumors the adenomata are most fre- 
quently met with. They arise from the mucosa, have a 
typical acinous structure, and are attached to the mucous 
membrane either by a broad base or by a pedicle. In the 
latter instance thej form polypoid excrescences which may 
cover long distances of the intestinal canal, existing in large 
numbers. Ewald refers to a specimen in his possession in 
which the inner wall of the colon was covered from the 
1 Madelung : Centralbl. f. Chirurgie, 1892, No. 30. 



174 DISEASES OF THE INTESTINES. 

splenic curvature to the sigmoid flexure with such numer- 
ous polypi that they projected from the mucous membrane 
like tassels from a ribbon. The whole specimen looked 
somewhat like a gigantic bunch of grapes. The polypi are 
most often met with in children from the fourth to the 
seventh year, although they also occur in grown-up per- 
sons. 

With regard to symptoms the benign tumors located in 
the upper parts of the intestinal tract cause hardly any 
disturbances at all. Sometimes, however, especially if 
they are present in larger numbers, they may give rise to 
hemorrhages and catarrhal affections. On account of their 
small size and soft consistency it is almost impossible to 
discover them by palpation through the abdominal wall. 
In very rare instances they may give rise to serious symp- 
toms by occluding the intestinal lumen or by causing in- 
vagination. The benign tumors located in the rectum 
more frequently give rise to disturbances. Thus tenesmus 
and difficult defecation are often met with; hemorrhages 
also occur frequently. Sometimes such a polypus, if situ- 
ated near the anus, may protrude through this opening 
during defecation and give rise to severe pains. Occasion- 
ally a polypus is torn off from the intestinal wall and 
passed with the stools. In such an event the symptoms, 
if there have been any, suddenly disappear. 

Whenever these tumors are situated in the lower rec- 
tum they are accessible to direct examination and treat- 
ment. The latter consists in removing them by galvano 
cautery or by direct surgical measures. 



CHAPTER VII. 

HEMOEEHOIDS. 

Synonyms : Plilebectasia hemorrhoidalis. Piles. 

Definition. — Diffuse or circumscribed varicose dilata- 
tions of the hemorrhoidal veins situated either in the sub- 
cutaneous tissue of the external surface of the anus or in 
the submucous tissue of the lower portion of the rectum. 

Etiology. — The affection under consideration is quite 
frequently met with. It occurs more often in men than in 
women and very rarely in children. While in olden times 
it was believed that hemorrhoids were due to a faulty state 
of the general circulation or dyscrasia, it is now generally ac- 
cepted that they are the result of merely local disturbances. 
The development of hemorrhoidal varices takes place in 
the same manner as that of varices of other regions of the 
body, principally by mechanical influences. The reason 
why these phlebectases are formed so often in the hemor- 
rhoidal plexus is as follows: 1. The hemorrhoidal veins 
occupy a low position of the body, no matter whether in 
the standing or in the recumbent posture. 2. They are 
often unduly compressed by the contraction of the muscles 
situated in the lower end of the rectum and by fecal masses 
accumulated here. The circulation is thus at certain times 
obstructed or altogether arrested. 3. The hemorrhoidal 
veins are not provided with valves, and thus blood which 
has passed through them can be easily forced back. 4. 
The rectal veins are the remotest branches of the portal 



176 DISEASES OF THE INTESTINES. 

vein in which there is normally but a low degree of pres- 
sure, and in which circulation is easily retarded by dis- 
turbances of the liver. As a]l these factors exist even 
under normal conditions it is readily conceivable that 
phlebectases are found in the majority of people; usually, 
however, they do not reach a marked development, and 
for this reason do not give rise to complaints. 

All conditions which tend to produce lasting hyperemia 
of the lower portion of the rectum give rise to the develop- 
ment of hemorrhoids. Too prolonged sedentary or stand- 
ing occupations predispose to them. In this way hemor- 
rhoids occur in clerks, students, some artisans, for instance, 
shoemakers, tailors, and cavalrymen, seamstresses and 
washwomen, etc. High livers and people who are used 
to strongly seasoned or fatty foods also often suffer from 
piles on account of the great fulness of the portal circula- 
tion under these conditions. Habitual constipation also 
favors their development. The use of strong cathartics 
like aloes, colocynth, gamboge, etc., irritates the large 
bowel in a marked degree and often gives rise to hemor- 
rhoids. Diseases of the uterus which lead to an enlarge- 
ment of this organ and also pregnancy are predisposing 
causes. In a similar way affections of the prostate and 
tumors of the bladder as well as of other organs situated 
in the small pelvis often produce hemorrhoids. All dis- 
eases of the liver which are accompanied by a congestive 
state of the portal circulation exert a direct influence upon 
their formation. Diseases of the heart and lungs fre- 
quently cause congestion of the inferior vena cava and 
indirectly also of the rectal veins, thus predisposing to 
the affection under consideration. 

Hemorrhoids are most frequently developed between the 
ages of thirty and fifty years. They are extremely rare 



HEMORRHOIDS. 177 

in infants and children. With regard to frequency the 
male sex seems to be more often afflicted than the female. 
Some races show a special predisposition to this disease, 
depending most probably upon their mode of living and 
their diet. Whether heredity plays a part in the develop- 
ment of hemorrhoids is yet unsettled. 

Morbid Anatomy. — In some instances the hemorrhoidal 
veins are evenly dilated and can be noticed as bluish-red 
and tortuous vessels encircling the external anal opening. 
At the same time there may be no special varicose swell- 
ings; more frequently, however, besides the general con- 
gested condition of the veins thare are isolated varicose 
protrusions which may range in size from a pea to a wal- 
nut. They vary greatly in shape: sometimes they are 
round, sometimes flat, sometimes again irregular. Their 
size greatly changes from time to time in the same person. 
After defecation as a rule they grow smaller. Internal 
hemorrhoids appear as soft nodules of a bluish hue and 
have thin walls. They often develop to a considerable 
size and make defecation difficult. As a rule, hemorrhoids 
occur as multiple nodules, which may cover the mucous 
membrane at different places, or they may encircle the 
external surface of the anus, or be situated above the inter- 
nal sphincter. Internal and external hemorrhoids may 
also be present at the same time. Thus Cruveilhier l de- 
scribed a case in which there existed a wreath of external 
hemorrhoids around the anal opening, another above the in- 
ternal sphincter, and a third a few centimetres farther up. 

External hemorrhoids are at first covered with normal 
epidermis which can be moved over them. Later, how- 
ever, through inflammatory processes the cutis becomes 
adherent to the varicose nodule. At the same time the 

1 Cruveilhier : " Traite d'anatomie pathologique generate, " 1849. 
12 



178 DISEASES OF THE INTESTINES. 

skin covering the nodule grows thinner through the steady 
pressure to which it is subjected, and it may reach a point 
when it breaks open after a forced defecation. The same 
remarks also apply to internal hemorrhoids in which the 
cutaneous covering of external hemorrhoids is represented 
by the mucous membrane of the bowel. This also be- 
comes adherent, thinned, and may ultimately rupture. 

Internal piles are best divided, according to Allingham, 1 
into the three following varieties : 

1. Capillary Piles. These present small, florid, rasp- 
berry-looking tumors or rather vascular areas upon the 
mucous membrane, having a granular spongy surface and 
bleeding on the slightest touch; they are often situated 
rather high in the bowel ; in structure they consist almost 
entirely of hypertrophic capillary vessels and spongy con- 
nective tissue. They resemble arterial naevi very closely, 
indeed, in their microscopical structure, except that they 
are covered externally by a very much thinner membrane 
and consequently are readily made to bleed. 

2. Arterial Piles. These appear as tumors varying in 
size, sessile or somewhat pedunculated, attaining sometimes 
very considerable dimensions, glistening or slightly villous 
on their surface, slippery to the touch, hard and vascular 
with an artery often as large as the radial entering their 
upper part. When they are villous on their surface, they 
bleed very freely and for some reason or other have formed 
and grown very rapidly. On dissecting one of these tumors 
one will find that it consists of numerous arteries and 
veins frequently anastomosing, tortuous, and sometimes 
dilated into pouches, and of a stroma of cell growth and 
connective tissue, the latter most abundant. 

1 William xlllingham and Herbert W. Allingham : u The Diagnosis 
and Treatment of Diseases of the Rectum. " London, 1896, p. 113. 



HEMORRHOIDS. 179 

3. Venous Piles. In these the venous system predomi- 
nates. The tumors are often very large and are sometimes 
the size of a hen's egg. They are bluish or livid in color. 
The surface may be smooth and shiny or pseudocutaneous. 

External and internal piles often present themselves as 
nodules situated closely to each other and sometimes coa- 
lescing ; thus larger tumors arise. In these hemorrhoidal 
varices important structural changes frequently take place. 
While at first soft, they may grow quite hard by the for- 
mation of blood clots or by a process of calcification. In- 
flammatory processes in the neighboring tissue have a 
tendency to increase their size and to make them more 
firm. 

Internal piles are often pushed downward during the act 
of defecation. In this manner the mucous membrane of 
the base of the tumor is subjected to greater traction, and 
thus ultimately a pedicle is formed. Such nodules pro- 
vided with more or less long pedicles and situated near 
the internal sphincter very frequently slip out from the 
anus at each defecation. When, however, they are not 
especially large, they spontaneously return into the rectum 
after defecation is finished. If they are of considerable 
size, it sometimes happens that they become incarcerated 
by the external sphincter, and if not carefully replaced, 
inflammation may develop and give rise to intense pains. 
Occasionally they may even become gangrenous and ulti- 
mately drop off. In some instances hemorrhoids undergo 
retrograde changes, become smaller, and even disappear 
entirely. Flaps of skin hanging near the anus and pre- 
senting a brownish color are often the remnants of pre- 
vious piles. External j)iles sometimes give rise to the 
formation of warts and their surface assumes an uneven 
and wrinkled appearance. Internal hemorrhoids are often 



180 DISEASES OF THE INTESTINES. 

complicated by inflammatory processes of the neighboring 
tissues. Such processes give rise to the formation of ul- 
cers, proctitis, and periproctitis. In the latter instance 
an abscess may be formed, which may open either exter- 
nally or internally, sometimes both ways. Thus a com- 
plete rectal fistula originates. 

In internal hemorrhoids the mucous membrane of the 
rectum almost always exhibits the signs of a chronic ca- 
tarrh. Its surface is swollen, succulent, and often covered 
with a thick layer of mucus. Occasionally there may be 
some pus. The proctitis accompanying piles may be either 
the cause or the sequel of the latter ; sometimes, however, 
both may be due to some other factor. 

Symptomatology . — Most of the symptoms produced by 
hemorrhoids are generally of a local character. They 
greatly vary in the different varieties of piles. In the 
early stage of external pile there occur off and on, espe- 
cially after indiscretions in eating and drinking (princi- 
pally effervescent wines or strong alcoholic beverages), 
attacks caused by an increased congestion of the hemor- 
rhoids. These attacks may be described as follows: A 
sensation of fulness or clogging and slight pulsation in the 
anus are felt by the patient. Moderate constipation exists, 
compelling the patient to strain more than ordinarily. 
Itching of the anal region and the perineum frequently 
annoy the patient, especially soon a f ter retiring, and may 
keep him awake for quite some time. On awaking in the 
morning the patient finds the anus tender and swollen, 
and after a movement a few stains of blood are discov- 
ered on the paper. Such an attack will, as a rule, pass off 
very quickly if the patient lives rationally and avoids the 
predisposing causes; if not, the attack will quickly recur 
with greater intensity and gradually assume a severer type. 



HEMORRHOIDS. 181 

External piles may become swollen and cedematous, and 
are then extremely painful to touch. Sometimes there 
may be ulceration, or suppuration may take place and 
small painful fistulae may form. The venous tumors now 
and then irritate the sphincter and levator ani muscles and 
produce spasm of the latter. The piles are then occasion- 
ally drawn up into the anus and pinched by the latter. 
This causes a great deal of pain and keeps the patient 
awake during the night. A feeling of throbbing and a 
sensation as of a foreign body in the anus exist. A fre- 
quent desire for defecation is thereby produced and the 
patient, as a rule, is inclined to attempt to expel the for- 
eign body by forcible straining, which of course only 
aggravates the pain. Under these circumstances the 
patient can hardly sit down nor can he walk about com- 
fortably, and on coughing and sneezing experiences great 
suffering on account of the constriction of the involved 
diseased parts. During a movement of the bowel and for 
some hours afterward the pains are greatly increased. 
The patient is unable to attend to his daily occupation. 
General symptoms like fever, anorexia, dizziness, severe 
constipation, may accompany the local manifestations. 

Of the internal hemorrhoids, the capillary variety, being 
small and only slightly elevated above the mucous surface, 
gives rise to scarcely any trouble. As a rule, there is no 
pain. Occasionally, however, ulceration takes place which 
may cause considerable suffering. 

Arterial and venous hemorrhoids give rise to many more 
symptoms. In case the sphincter muscles are relaxed, the 
hemorrhoids often protrude on the slightest exertion. 
This also often occurs at stool. At first they spontane- 
ously return within the sphincter after the bowels have 
moved or whenever the exertion has ceased. Later in the 



182 DISEASES OF THE INTESTINES. 

course of the disease, however, the patient is compelled to 
return them with the ringer. In still more advanced cases 
they never remain long within the sphincter and pro- 
trude very often whenever the least exertion is made. In 
this manner the hemorrhoids cause much discomfort. 
They also discharge a gummy acrid mucus which keeps 
the parts constantly moist and leads to excoriations around 
the anus, and also favors the development of cutaneous 
excrescences. Patients with fully developed internal hem- 
orrhoids experience a great deal of suffering during defe- 
cation. They also feel quite uncomfortable for some time 
afterward, occasionally to such a degree that they have to 
lie down. When walking they are always conscious of the 
fact that they have an anus. 

In other instances in which the sphincter ani is strong 
and tight, the piles in coming down become nipped and 
their return is rendered difficult and painful. 

The symptom from which the hemorrhoids originally 
derived their name, namely, hemorrhage, is common to all 
varieties of piles, although it is by no means constant. In 
many instances it is absent, or it does not play any essen- 
tial part, especially in external piles. In some patients a 
more or less considerable hemorrhage takes place at cer- 
tain intervals, appearing periodically, occasionally with 
great regularity. A few premonitory signs, consisting in 
painful sensations in the back and around the anus, con- 
stipation, and other indefinite nervous symptoms usually 
precede for a few days the beginning hemorrhage. The 
blood as a rule then appears at first in small quantities 
gradually increases in amount, and the hemorrhage stops 
on the fifth or sixth day after its commencement. Physi- 
cians in olden times— and some of the laity even nowadays 
— looked upon the hemorrhage as an inrportant event, free- 



HEMORRHOIDS. 183 

ing the system of vicious material. This is the reason why 
formerly the hemorrhoidal bleeding was termed the golden 
flow. Nowadays we do not attach any particular import- 
ance to these hemorrhages. Their regularity or the perio- 
dicity of their appearance is simply attributable to the 
fact that the time necesary for the filling up of the nodules 
until they rupture is usually of the same length. 

In some instances there are transient hemorrhages, last- 
ing a shorter or longer period. Ordinarily the patients feel 
relieved after the bleeding ; occasionally they remain quite 
well for a long time, sometimes for a year or two, until 
there is suddenly a new hemorrhage. In the latter case 
the hemorrhage is commonly caused by some unusual oc- 
currence ; thus, a very copious meal, a long ride on horse- 
back, or an excess in venery may bring it on. 

In another class of patients there may be continuous 
small hemorrhages. These occur more frequently in cases 
of capillary hemorrhoids. The quantity of blood lost at 
each action of the bowel is small, but being steady it be- 
comes a serious strain upon the patient's constitution and 
may give rise to severe forms of anaemia and even per- 
nicious anaemia. 

The blood discharged from piles is either of a bright 
red or a dark brown color, depending upon its origin from 
arteries or veins. It is characteristic of hemorrhoidal 
hemorrhages that the blood usually appears in a liquid, 
non-coagulated state, covering the fecal matter, but not 
mixed with it. If the hemorrhage is very copious, uncon- 
sciousness may result combined with symptoms of pro- 
found collapse. This, however, happens very rarely. Ac- 
companying the local manifestations, especially if the latter 
are of a high degree, there may be varied general symp- 
toms. Thus dyspnoea, palpitations of the heart, angina 



184 DISEASES OF THE INTESTINES. 

pectoris, irregular heart action, hiccough, headaches, gid- 
diness, dizziness, buzzing in the ears, and cloudy vision 
may be present. Often a despondent feeling and a condi- 
tion resembling hypochondria is met with. Anorexia, 
nausea, belching, and constipation also often occur. The 
general symptoms are especially marked if incarceration 
of internal piles within the sphincter has taken place. In 
case the swelling of the hemorrhoids is so extensive that 
a reposition cannot be quickly effected, there may be pres- 
ent besides the local pains high fever and signs of col- 
lapse. If the incarceration lasts a long period, the hem- 
orrhoids may become gangrenous and either fall off, 
accompanied by profuse hemorrhage, or, although rarely, 
give rise to septic and peritonitic conditions. In most 
instances after a falling off of the hemorrhoid a sponta- 
neous cure takes place. 

Some cases of hemorrhoids are complicated with catarrh 
of the rectum (proctitis). In such instances the stools 
reveal the presence of a considerable quantity of mucus, 
occasionally even of pus. Sometimes the mucous or mu- 
co-purulent fluid admixed with the faeces may be tinged 
with blood. These cases are often accompanied by a 
paretic condition of the sphincters, which allow the secre- 
tion to dribble from the anus. This gives rise to excoria- 
tions and inflammation of the anus and the neighboring 
tissues. In the course of the proctitis prolonged tenesmus 
may appear at times. If the inflammation extends into the 
rectal cellular tissue, it may lead to the formation of ab- 
scesses which may empty into or outside the bowel. This 
is the most frequent way in which fistulae are produced. 

Disturbances of the adjacent organs are also occasion- 
ally met with in cases of piles. Thus ischuria, stranguria, 
.hemorrhages from the bladder, hemorrhages from the va- 



HEMORRHOIDS. 185 

gina, and catarrhal conditions of the latter are encoun- 
tered. 

Diagnosis. — The diagnosis of hemorrhoids as a rule is 
easy. External piles are found by inspection of the anus, 
the patient lying on his side with the thighs drawn up. 
The buttocks are pushed aside with the hands, and the 
patient is instructed to strain in a similar manner as when 
having a stool. Nodules of a reddish-bluish tinge will be 
noticed in the immediate vicinity of the anus or partly 
within it. It is characteristic of hemorrhoidal nodules 
to increase in size during a period of constipation, and to 
diminish after an efficient evacuation of the bowels. 

Condylomata and small skin tags around the anus can be 
easily differentiated from piles. Condylomata, as a rule, 
encircle the anus and are present also on other parts of the 
body, especially on the scrotum. Besides, there will be 
a previous history of syphilis, and occasionally other lue- 
tic manifestations. The cutaneous tags present more the 
appearance of whitish-looking skin, never change in size, 
and do not bleed when punctured, while hemorrhoids 
bleed profusely on puncture. 

The diagnosis of internal hemorrhoids can be made by a 
digital examination or by this in connection with the in- 
spection of the lower portion of the rectum by means of a 
speculum. The characteristics of internal piles are similar 
to those of external hemorrhoids. They can be easily 
differentiated from polypi by means of puncture with the 
needle. Polypi do not bleed when punctured. Besides, 
polypi are usually found in children, while hemorrhoids 
occur with greatest frequency in the advanced period of 
life. 

Carcinoma of the rectum will rarely give rise to mistakes, 
the tumor usually presenting a much harder consistency 



186 DISEASES OF THE INTESTINES. 

than hemorrhoids. As a rule, there will also be other 
signs of a malignant trouble, cachexia, etc. It is needless 
to say that cancer of the rectum may be combined with 
hemorrhoids. As a matter of fact, it very often gives rise 
to their development, and the discovery of piles which 
have formed within a short period of time should indeed 
rouse the suspicion of caDcer of the rectum. 

Prognosis. — The prognosis of external as well as internal 
piles is as a rule favorable. They generally exist for a 
long time, not infrequently throughout life. They hardly 
ever endanger life, unless some grave complications (incar- 
ceration of the hemorrhoids or gangrenous processes or 
very profuse hemorrhages) supervene. Hemorrhoids are 
liable to recede or even to disappear entirely, especially if 
the factors producing them have been eliminated. 

Treatment. — A rational mode of living is of the greatest 
importance. Patients with hemorrhoids should have 
plenty of outdoor exercise, should partake of food with 
moderation, should avoid all excesses in baccho and in 
venere, and should endeavor to have a daily evacuation of 
the bowels. Any condition causing venous hyperemia of 
the rectum must be removed. Thus vocations requiring 
constant sitting, or constant standing, or horseback riding 
should be entirely or partly given up. 

With regard to diet the following general rules may be 
given: Patients with hemorrhoids should avoid copious 
meals. They should rather eat often and sparingly. Fish, 
fresh, well-cooked vegetables, and ripe fruit should form a 
considerable part of their diet. Alcoholic beverages, strong 
coffee, and highly seasoned dishes should be avoided. The 
different kinds of cheese, very coarse brown bread, cabbage, 
peas, and beans are best eliminated from the diet. Salads, 
potatoes, beets, spinach, asparagus, cauliflower, are, how- 



HEMORRHOIDS. 187 

ever, rather of benefit if taken in small quantities, as these 
articles make the intestinal contents more liquid. Stewed 
fruits and also raw fruit, as for instance apples, pears, 
prunes, oranges, grapes, are useful. As a beverage, plain 
water, best taken between meals in the quantity of a pint, 
is most beneficial. In some instances, especially in anae- 
mic patients, buttermilk in the same quantity may be 
taken instead of water. A small amount of light beer is 
permissible in some cases. 

With reference to hygiene or prophylactic measures it 
is of importance for the patients to have plenty of outdoor 
exercise, especially walking. The exercise, however, should 
not be continued to over-fatigue. Gymnastic exercises at 
home, sawing or chopping wood, and the like, and also 
massage are best adapted for this purpose. The patients 
should wash the affected part in the morning and evening 
with cool water. They should sit on caned chairs, not on 
upholstered ones, and should sleep on a mattress. 

The patient should have a good evacuation of the bowels 
daily. In case this does not occur, it will be of the great- 
est importance to secure it by the different therapeutic 
measures at our disposal (see Chapter X., on constipa- 
tion). As a rule, however, powerful laxative and drastic 
remedies should be avoided. The frequent use of injec- 
tions had also best be omitted. The purgatives most 
adapted for these patients are the saline ones, sulphur and 
rhubarb drugs. Thus compound licorice powder, a tea- 
spoonful in the evening, or sulph. depur., potas. bitartrat. 
aa, also one teaspoonful in the evening. Ehubarb in the 
form of tincture or in substance 0.5 to 1 gm., taken once 
or twice daily, is also advantageous for a prolonged use. 
The waters of Carlsbad, Kissingen, Marienbad, Tarasp, 
Saratoga, will also be of benefit, especially if taken at the 



188 DISEASES OF THE INTESTINES. 

watering-places themselves in connection with a prescribed 
diet. If the hemorrhoids have already attained consider- 
able size, local remedies will often be required. 

Local Treatment. — The irritation or the rubbing of the 
piles against each other or against the skin must be pre- 
vented. For this purpose covering the piles with a small 
piece of smooth and clean cotton is of benefit ; still better, 
however, for this purpose is cotton moistened in olive oil 
or covered with vaseline or a soft salve (Hebra's ointment 
or ointments of zinc, lead, boracic acid) . If the piles are 
inflamed, it is best to first paint them a few times with the 
following solution : 

^ Potas. iodidi 2.0 ( 3 ss. ) 

Iodi puri 0.2 (gr. iiiss.) 

Glycerin 40.0 ( 3 x.) 

before applying the ointment. After a movement the anus 
and the piles should be first washed with cool water and 
then wiped off with soft cotton or linen. This must be 
done very gently. Persons suffering with annoying tenes- 
mus after defecation should accustom themselves to go to 
stool before retiring. The recumbent position which the 
patients are thus able to assume soon after the passage 
affords them decided relief. 

If there are pains in the rectum caused by a mere hyper- 
esthesia of the mucous membrane, an injection of one to 
two teaspoonfuis of warm olive oil or of the same quantity 
of warm water into the bowel will exert a favorable influ- 
ence. If this fails, or in cases in which the pains are 
caused by a superficial excoriation of the piles, it is best 
to apply an ointment containing some narcotic after an 
evacuation of the bowels, and sometimes even during the 
intervals. The following salve, recommended by Rosen- 
heim, is very appropriate : 



HEMORRHOIDS. 189 

3 Lanolin 20.0 ( 3 v. ) 

Bism. subnitr 2.0 ( 3 ss.) 

Extr. opii 0. 3 (gr. v. ) 

M. f. uiigt. 

In place of the ointment the piles may be painted with a 
solution containing equal parts of fluid extracts of opium 
and belladonna, or with a two-per-cent cocaine solution. 
Suppositories containing opium, belladonna, or cocaine 
are also effectual. 

Internal piles prolapsing through the anus should be 
pushed back by the patient after anointing them with olive 
oil or with vaseline. In case the reposition is not easy, 
painting of the piles with a two-per-cent cocaine solution 
will after a while lessen the sensitiveness and thus make re- 
position possible. In some obstinate cases the patient must 
be narcotized in order to accomplish this. If the incarcerat- 
ed piles have already become gangrenous, the pains usually 
grow less. In order to arrest the necrotic process it is 
advisable to dust the affected area with an antiseptic powder 
(dermatol) and to cover it with dry gauze. The pile usu- 
ally falls off spontaneously and the wound heals of itself. 

The inflammatory processes in piles require special 
treatment in the stage of exacerbation (general antiphlo- 
gistic remedies) . Thus rest in bed on the side, applica- 
tion of cold in the form of an icebag or a Priessnitz poultice, 
occasionally leeches in the neighborhood of the amis, not on 
the piles themselves, are beneficial. Application of cold lead, 
water is also useful. In case there are signs pointing to 
the formation of pus or the development of a septic process, 
surgical intervention is imperative. An incision into the 
hardened piles followed by thorough extirpation is essential. 
Inasmuch as such an operation must be done under chloro- 
form narcosis, the radical removal of the entire hemor- 
rhoidal area is therefore best performed at the same time. 



190 DISEASES OF THE INTESTINES. 

Hemorrhoidal hemorrhages, if not extensive, and if occur- 
ring at long intervals, will hardly require any therapeutic 
measures. If, however, the quantity of blood is quite con- 
siderable or if the hemorrhage is protracted, the following 
means should be employed : An icebag should be applied 
to the anus for several hours, or in case the hemorrhage 
results from internal piles, a cylindrical piece of ice is 
pushed up into the anus and replaced every half-hour. 
The rectal refrigerator may likewise be used with benefit. 
Tery cold injections are also useful. In cases with very 
frequent hemorrhages injections of water, to which an as- 
tringent remedy has been added, are beneficial. Thus a 
two-per-cent solution of tannic acid or of alum, or a 0.3- 
per-cent solution of acetate of lead may be applied. Su- 
prarenal gland applied locally in powdered form or used 
in a salve vehicle or suppository — also adrenalin adminis- 
tered in solution (1 : 10,000) — are of decided benefit. The 
following ointment, first suggested by Kossobudskj, 1 may 
also be applied in these cases : 

fy Chrysarobin 0.8 (gr. xiij.) 

Iodoform 0. 3 (gr. v.) 

Extr. bellad 0.6 (gr. x.) 

Vaselini 15.0(1 ss.) 

M. f. ungt. 

This salve not only checks the hemorrhage, but has also 
an excellent effect in reducing the size of the pile. In in- 
ternal hemorrhoids the following suppository may be used 
for the same purpose : 

^ Chrysarobin 0. 1 (gr. if) 

Acidi tannici 0.1 (gr. if) 

Iodoform 0.2 (gr. iiif) 

Extr. opii 0.02 (gr. f) 

01. theobrom 2.0 (3 ss.) 

M. f. Suppository. S. One suppository in the evening. 

1 Kossobudski: Central blatt fi'ir Chirurgie. lBtffl. 



HEMORRHOIDS. 191 

Radical Treatmen t. — 1 . Dilatation of the Sphincters. Ver- 
neuil ' was the first to recommend dilatation of the sphinc- 
ters as a cure for piles. This treatment is based upon the 
idea that the spasm of the sphincter is thereby stopped, 
that the bowels act more freely and the pressure upon the 
venous blood-vessels is relieved. The dilatation of the 
sphincters may be accomplished gradually by introducing 
specula into the rectum, taking a larger size each time, 
which procedure occupies several weeks, or it may be done 
in one sitting (the so-called forcible dilatation). In the 
latter instance, however, chloroform narcosis is necessary. 
Complete dilatation is effected, according to Allingham, in 
the following way : The patient being fully under the influ- 
ence of ether or chloroform, both thumbs must be inserted 
into the rectum, which is to be dilated gradually, first in 
the antero-posterior and afterward in the opposite direc- 
tion. The amount of force used must be sufficient to over- 
come the spasm thoroughly. This manipulation must be 
continued until the sphincter muscles yield, as if reduced 
to a really pulpy condition. Care must be taken to act 
high enough up in the rectum so as to include the whole 
of the sphincter. The result is that the state of contrac- 
tion is abolished and no spasm can occur. In fact, for the 
time being, as in any other stretched muscle, paralysis re- 
sults. With great gentleness the desired effect may be ac- 
complished without tearing the mucous membrane. But 
some extravasation is usually noted around the anus for a 
few days. After this an opium suppository is kept in the 
rectum and the patient is placed in bed in a recumbent 
position. Dilatation of the sphincters may be recom- 
mended in the early stage of hemorrhoids, especially in 
cases combined with constipation ; further in hemorrhoids 
1 Verneuil : Gazette des hop., 1884, 1887. 



192 DISEASES OF THE INTESTINES. 

during pregnancy or occurring in persons greatly debili- 
tated by other grave diseases. 

2. Carbolic-Acid Injections. Pooley, ■ Kelsey , 2 Roux, 3 and 
Lange 4 have recommended injections of carbolic acid into 
the piles in order to produce shrinking. This method is per- 
missible only if the hemorrhoids are not inflamed. Proceed 
as follows: The piles are first thoroughly cleansed and 
dried, then covered with iodoform salve. In order to 
lessen the pains a few drops of a one-per-cent cocaine so- 
lution may first be used subcutaneously. Then three to 
fixe drops of either of the two following solutions are in- 
jected into the centre of each pile: (1) Carbolic acidl, gly- 
cerin 3; (2) Carbolic acid 1, glycerin 3, distilled water 3. 
The injection is made with the common Pravaz syringe, 
but care must be taken that none of the solution drips from 
the needle, so as to avoid cauterizing the mucous mem- 
brane. Several piles can be treated at the same sitting. 
It is advisable, however, not to make the injections oftener 
than about once a week. This procedure if carefully done 
is not dangerous nor painful, and often effects shrinking 
or even disappearance of quite considerable hemorrhoidal 
nodules. 

3. Cauterization ivitli Fuming Nitric Acid. Houston, 5 of 
Dublin, was the first to recommend cauterization of piles 
with fuming nitric acid. This may be done in the follow- 
ing manner : After thorough cleansing and drying of the 
anus and the surrounding parts, the entire area is covered 

1 J. H. Pooley : "Injection of Carbolic Acid in Hemorrhoids." To- 
ledo Med. and Surg. Journal, November, 1877. No. 11. 

2 Charles B. Kelsey : " The Treatment of Hemorrhoids. " Medical 
Record, 1886, vol. ii., p. 141. 

3 Roux: "Behandlung der Hamorrhoiden." Therap. Monatshefte, 
1895, p. 124. 

4 F. Lange : Centralblatt fur Chirurgie, 1887, No. 25, Beilage, p. 70. 
6 Houston : Dublin Journal of Medicine, 1844. 



HEMORRHOIDS. 193 

with a thick layer of vaseline excepting the pile which is 
to be treated. The latter is then painted with nitric acid 
by means of a small stick of wood or a glass rod. Special 
care must be taken that the acid reaches no other spot. 
After the nodule has assumed a grayish-green color it is 
carefully dried, smeared with vaseline, and pushed back 
into the rectum. This method is best adapted for smaller 
nodules, especially if they have a wide base. Sometimes 
a second cauterization is necessary, which may be done 
after an interval of about five days or a week. Instead of 
nitric acid other cauterizing substances may be used, and 
Allingham has recommended concentrated carbolic acid as 
especially efficient for this purpose. 

4. Ligature. Cooper ' recommended the ligature of hem- 
orrhoids in order to cut them off from the circulation and 
thus destroy them. Salmon 2 has improved this method 
by making an incision before applying the ligature. Ac- 
cording to this writer, the operation is performed in the 
following manner : The patient is placed on the right side 
on a hard couch and is completely anaesthetized. The 
sphincter muscles are then gently but completely dilated. 
The hemorrhoids, one by one, are then drawn down with a 
pronged hook fork ; by means of sharp scissors the pile is 
separated from its connections with the muscular and sub- 
mucous tissues upon which it rests. The cut is best made 
in the sulcus or white mark which is seen where the skin 
meets the mucous membrane. This incision is made in a 
. direction parallel to the bowel and carried to such a dis- 
tance that the pile is left connected by an isthmus of vessels 
and mucous membrane only. A well-waxed, strong, thin, 
aseptic silk ligature is now placed at the bottom of the deep 

1 Cited from Allingham, loc. cit. 
8 Ibid. 
13 



194 DISEASES OF THE INTESTINES. 

groove which has been made, and the ligature is tied right 
at the neck of the tumor as tightly as possible. When all 
the hemorrhoids have thus been ligated, they should be 
returned within the sphincter. A small piece of absor- 
bent cotton saturated with iodoform ointment is now 
placed into the bowel and a pad of cotton applied over the 
anus. 

5. Crushing. Crushing of piles has been suggested by 
Pollock and the method further improved by Allingham, 1 
who devised a very ingenious apparatus for this purpose, 
namely, the "screw-crushing instrument." The operation 
begins with the dilatation of the sphincters. The hemor- 
rhoid is then drawn into the screw-crusher by means of a 
hook, and this being intrusted to an assistant the bar is 
pushed up and screwed home as tightly as possible. The 
pile should be crushed longitudinally and not transversely. 
The projecting portion of the pile is cut off with the knife 
or scissors and the pressure kept up for about one minute. 
According to Allingham crushing is a very satisfactory 
method of removing internal piles. 

6. Thermo-cautery (Paquelin) and Galvano-cautery. Lan- 
genbeck introduced the method of operating upon piles 
by means of thermo-cautery. Each pile is seized with a 
volsellum forceps and drawn well down. The clamp is 
then applied so as to embrace its base. The portion above 
the clamp is cut off with a pair of scissors and the cautery- 
iron, heated to a dull red heat, is repeatedly applied to the 
stump until all the vessels are well seared. 

Instead of using the Paquelin, galvano-cautery may be 
applied for the removal of hemorrhoids, the technique 
being identical with the former. Bardeleben and also Ro- 
senheim strongly recommend the latter method. 

1 Allingham : "Diseases of the Rectum," 1896, p. 153. 



HEMORRHOIDS. 195 

7. Extirpation of Hemorrhoids, followed by Suture. This 
method was first introduced by von Esmarch * in Germany 
and by Whitehead in England. It is not, however, exten- 
sively used as it is quite complicated, besides giving rise to 
many disagreeable complications, Thus Allingham has 
noticed the following sequels of such an operation: 1. Anal 
stricture. 2. Loss of sensation and control over the 
anus. 3. Irritation of the mucous membrane due to fre- 
quent discharges of mucus and at times accompanied by 
bleeding. 

After any of the above-named operations it was customary 
to employ an astringent in order to prevent a movement 
of the bowels for a few days. Contrary to this method E. 
Graser 2 is of the opinion that such patients are better off 
when having a free movement shortly after the operation. 
He administers soon after its performance a small dose of 
castor oil and instructs the patient to have an evacuation 
while in a warm sitz bath. Cleansing of the anus is very 
easily obtained in this manner. After an antiseptic wash- 
ing a piece of cotton or linen, thickly smeared with an 
ointment, is introduced into the rectum. This procedure 
has usually to be performed once daily. According to 
Graser, the patients if thus treated are almost without pain, 
and are able to get up and be out of bed five or seven 
day s after the operation. For some time after its perform- 
ance it is advisable to have the patient introduce bougies 
of varying size into the rectum in order to prevent the for- 
mation of a stricture. 

Complications. — Prolapse of the Rectum. Prolapse of the 
rectum is a frequent complication of hemorrhoids, although 

Won Esmarch: "Die Krankheiten des Mastdarms und Afters," 
Stuttgart, 1887. 

2 E. Graser : Penzoldt u. Stinzing, "Handbuch d. Therapie, " Bd. iv., 
p. 634. 



196 DISEASES OF THE INTESTINES. 

it may also occur alone. The prolapse may involve either 
the mucous membrane alone or all the coats of the rectum. 
In the latter instance this condition is also called proci- 
dentia recti. Outside of the anus ther9 is a protrusion of 
the mucous membrane in its entire circumference. An 
internal prolapse of the rectum may also occur, which con- 
sists in the descent of the upper part of the rectum through 
the lower part, but not appearing outside the anus. This 
corresponds rather to an intussusception. A relaxation of 
the ligaments which serve to keep the rectum in its place 
is often the cause of this malady. Weakness and paralysis 
of the sphincter ani muscles are also predisposing factors. 

Prolapse of the rectum is frequently found in debilitated 
children, especially if an intestinal catarrh is present, for 
these little patients go to stool too often and usually strain 
too much and for too long a time. These conditions weaken 
the muscular apparatus of the anus, and thus a prolapse of 
the rectum easily arises. In elderly people, in patients 
suffering from affections of the bladder or from severe 
constipation and internal hemorrhoids, and in women 
who have gone through many pregnancies in quick suc- 
cession, prolapse of the rectum is also a frequent oc- 
currence. 

The symptoms are as follows : If the prolapse is only of 
a moderate degree, there appears in the act of defecation a 
protrusion of the rectum outside the anus, one or one and 
a half inches in length, the mucosa looking quite red and 
puckered. In the more advanced stage the bulged out 
rectum resembles a large tumor with a star-like opening 
at its centre, while the color is pale or bluish-red. In 
children the mass generally protrudes only on going to 
stool, but in adults it is constantly down or comes down 
on the slightest exertion, and therefore may become ulcer- 



HEMORRHOIDS. 197 

ated or inflamed. In old cases of prolapse incontinence 
of faeces is also frequently present. 

The diagnosis of prolapse of the rectum- is easily made 
from the above-mentioned appearances. Internal prolapse 
is net so easily diagnosed, as the mass never appears out- 
side the anus. This condition can be recognized only by 
means of a digital examination of the rectum. The finger 
introduced into the bowel is first kept close to the anterior or 
posterior wall, and is passed up until it meets with an ob- 
struction (i.e., it has passed into the cul-de-sac). Then 
the finger is slightly withdrawn and the centre of the gut 
examined until an orifice is found into which the finger or 
a bougie may be passed for some inches high up into the 
rectum. If the intussusception is rather far up in the rec- 
tum, the patient should bear down during the examination. 

With regard to treatment it is of importance to eliminate 
all the conditions which were predisposing factors for the 
prolapse. Extreme cleanliness, especially after defecation, 
should be observed. The reposition of the prolapse should 
be performed in the most careful manner. It is best done 
in the knee-elbow posture. If a considerable portion of 
the bowel has come down, a large flexible bougie may be 
passed into the bowel in such a manner as to carry before 
it the upper part of the descended gut. General taxis 
should at the same time be used, and in this way the mass 
can generally be returned. In cases in which the prolapse 
occurs quite frequently, even during a walk, a rectal sup- 
porter, as suggested by von Esmarch, should be worn by 
the patient. It consists of a soft-rubber ball attached to 
the anus by means of a belt and a T bandage. 

The palliative treatment which is especially successful in 
children is as follows : All sources of irritation should be re- 
moved and the general health strengthened. Straining at 



198 DISEASES OF THE INTESTINES. 

stool should be strongly forbidden and a mild laxative 
remedy given. After a movement of the bowels the pro- 
truded part should be well washed with cold water and 
pushed back into the anus by gentle pressure. After this 
procedure the patient should remain in a recumbent position 
for half an hour or so, best lying on the abdomen. If these 
means alone are not sufficient, the following more radical 
measures will have to be adopted : Cauterization of the pro- 
lapsed part with fuming nitric acid or with the thermo-cau- 
tery under chloroform narcosis is often of great benefit. 
Care should be taken while cauterizing not to touch the 
verge of the anus or the skin. After this the prolapsed 
part should be well oiled and returned. Instead of nitric 
acid Allingham uses the acid nitrate of mercury. 

These cauterizing methods have the disadvantage of often 
producing strictures of the rectum. For this reason a num- 
ber of surgical operations have been devised. Thus exci- 
sion of triangular or elliptical portions of the mucous mem- 
brane, bringing the edges together with sutures, has been 
practised. Extirpation of the entire prolapsed portion was 
first advocated by Treves. 1 F. Lange, 2 of New York, has 
described a new operation, serving the purpose of reduc- 
ing the calibre of the rectum and at the same time produc- 
ing a narrow muscular ring. The patient is placed in the 
genu-pectoral position, an incision is made from the lower 
part of the sacrum down to the anus, until the posterior 
wall of the rectum is reached ; the coccyx is then removed. 
The object in view is to narrow the gut as high as possible 
and to lessen the impediments to the action of the levator 
ani. The calibre of the rectum is lessened by introducing 
buried etage sutures of iodoformed catgut, which do not 

1 Treves : Lancet, 1890, vol. 1. 

2 F. Lange : Annals of Surgery, vol. v., p. 497. 



HEMORRHOIDS. 199 

perforate the entire thickness of the gut. The first rows 
are inserted near the middle line and form a fold in the 
posterior walls which protrudes into the bowel. In this 
manner the more lateral portions of the gut are brought 
into position without causing too much tension. Similar 
sutures are applied to unite the cut surfaces of the levator 
ani and sphincter externus, which had been previously dis- 
sected in order to lay bare the posterior wall of the rectum. 
The cavity thus formed is filled up with iodoform gauze 
and the flaps of integument are united with sutures. 

Another very efficient operation has been suggested by 
Allingham and consists in making a small incision through 
the anterior abdominal wall on the left side, just above the 
outer third of Poupart's ligament, then introducing the 
fingers into the abdomen, catching hold of the rectum and 
pulling it up. After it has been drawn as high up as pos- 
sible, silk threads are passed through the mesentery and 
the latter is fastened to the abdominal wall. 

Fissile of the Anus. Another affection which very fre- 
quently occurs in connection with hemorrhoids is anal fis- 
sure. The latter consists of an oblong tear of the mucosa 
of the anus and gives rise to severe pain and spasmodic 
contractions of the sphincters. Fissures or ulcers of the 
anus vary in depth and size. Some are mere abrasions of 
the mucous membrane, others are quite large and deep so 
that the muscular fibres are laid bare. The edges of the 
fissure may be in a healthy state or they may be inflamed, 
callous, and indurated. Fissure of the anus is usually 
caused by an injury or tearing of the mucous membrane 
at the verge of the anus. This may result either from ex- 
cessive straining or from the passage of very dry hard 
scybala. The affection is more often found in women than 
in men. The posterior portion of the anus is the point of 



200 DISEASES OF THE INTESTINES. 

predilection, although the fissure may occur at any other 
place. It is usually situated parallel to the external sphinc- 
ter, although in some instances it may lie higher up, par- 
allel to the internal sphincter or even above it. 

The symptoms consist in intense pains in the rectum on 
defecation, sometimes persisting afterward. The pains are 
often of a very excruciating character. The size of the fis- 
sure does not seem to be of so much importance with regard 
to the severity of the pain as its position. A small crack 
situated at the anal orifice over the external sphincter and 
involving the skin causes much greater pain than a large 
ulcer situated higher up in the rectum. There may also 
be a discharge of blood and pus. 

The diagnosis of anal fissure is made by the symptoms 
just mentioned and by local examinations. The patient 
lying on his left side should be told to bear down, and the 
anus opened with forefinger and thumb as gently as pos- 
sible. An elongated club-shaped ulcer will be seen within 
the orifice. Its floor may be very red and inflamed, or if 
the ulcer is of long standing, of a grayish color, with well- 
defined and hard edges. Often the introduction of the fin- 
ger into the anus is so painful that before making the ex- 
amination a suppository containing one grain of cocaine 
has to be applied. Sometimes even this procedure is in- 
sufficient, and then chloroform anaesthesia will be required. 
For a fissure situated higher up above the internal sphinc- 
ter examination with the speculum will have to be made. 

Fissures of recent origin can often be cured without any 
operation. Rest in the recumbent position should be 
adopted as much as possible. Mild laxatives are to be 
recommended, but no drastic remedies employed. If the 
patient can manage to have a movement at night time be- 
fore retiring, it will be of advantage. Locally the fissure 



HEMORRHOIDS. 201 

should be touched off and on with a ten-per-cent solution 
of cocaine or with a ten-per-cent solution of nitrate of sil- 
ver. Still better is the application of the following salve 
recommended by Allingham : 

IJ Hydrarg. subchlor gr. iv. 

Pulv. opii gr. ij. 

Extr. bellad gr. ij. 

Ung. sambuci 3 i. 

M. f. ung. 

If these palliative remedies are not sufficient, a free incision 
through the fissure should be made. The cut should be 
rather deep and should reach the sphincter muscles. 



CHAPTER VIII. 

APPENDICITIS. 

Synonyms: Scolecoiditis ; Perityphlitis; Paratyphlitis; 
Appendicular inflammation. 

Definition. — Inflammation of the appendix, characterized 
by localized pains, commonly fever and digestive disturb- 
ances. 

General Remarks. — The inflammatory lesions involving 
the right iliac region were formerly designated as typhlitis 
(inflammation of the caecum itself), perityphlitis (inflam- 
mation of the peritoneal covering of the caecum), and para- 
typhlitis (inflammation of the retro-peritoneal connective 
tissue of the caecum) . Grisolle 1 was the first to maintain 
that inflammation of the caecum could hardly give rise to 
such grave lesions as are found in the right iliac fossa, for 
even ulcerations of the caecum and colon do not, as a rule, 
show any tendency to extend into the neighboring connec- 
tive tissue. He ascribed the above conditions to an inflam- 
mation of the appendix, which organ shows a tendency 
to perforate and to lead to abscesses in the right iliac fossa 
as verified by post-mortem examinations. The possibility 
of a stercoral typhlitis (inflammation of the caecum as the 
result of accumulated fecal matter) which was formerly 
generally accepted, is now held by but very few writers, 

1 Grisolle : " Tumeurs Phlegmoneuses des Fosses Iliaques. " Archives 
de Medecine, 1839. 



APPENDICITIS. 203 

as for instance, Lennander. 1 Sahli, 2 Notlmagel, 3 Fow- 
ler, 4 Sonnenburg, 5 and others deny its existence. The 
teachings of Grisolle found further support through the 
brilliant investigations of Keginald Fitz 6 of Boston, 
Sands, 7 McBurney, 8 Weir, 9 Bull, 10 and Fowler of New 
York, were supplemented by the observations of Sonnen- 
burg, Sahli, Botter, 11 Boux, 12 Talamon, 13 and others, and 
are now generally accepted. 

Etiology. — In former years much importance was at- 
tributed to the occurrence of foreign bodies like cherry 
stones, grape seeds, lemon and orange pits, date kernels, 
fish bones, pins, etc., within the appendix as causative fac- 
tors of the inflammatory suppurative process. According 
to Fowler, the belief that the disease is frequently due to 
the engaging of foreign bodies in the cavity of the organ is 
based to a large extent upon purely speculative or imagi- 
nary conditions or erroneous observations. In a very large 
number of cases of this disease upon which he operated 
Fowler found but in two instances any body other than 
soft fecal masses which could be considered as being in 

1 Lennander : "Ueber Appendicitis, " Wien, 1895. 

2 Sahli : "Ueber das Wesen und die Behandlung der Perityphliti- 
den. " Correspondenzbl. f. Schweizer Aerzte, Basel, 1892. 

3 Nothnagel: " Krankbeiten des Darms, " Wien, 1898. 

4 George R. Fowler: "A Treatise on Appendicitis, " Philadelphia; 
1894. 

5 Sonnenburg : "Pathologie und Therapie der Perityphlitis, " Leip- 
zig, 1895. 

6 Reginald Fitz : American Journal of the Medical Sciences, 1886 j. 
and New York Medical Journal, 1888. 

' Sands : New York Medical Journal, 1888, p. 197-205, 607. 

8 Charles McBurney : Annals of Surgery, 1891 ; Medical Record, 1892. 

9 Robert F. Weir: Medical Record and Medical News, 1887-1892. 

10 W. T. Bull : Medical Record, 1894. 

11 Rotter : "Ueber Perityphlitis, " Berlin, 1897. 

12 Roux : Revue de Medecine de la Suisse romande, 1890, 1891, 1892. 

13 Talamon : " Appendicite et Perityphlite, " Paris, 1892. 



204 DISEASES OF THE INTESTINES. 

any sense foreign. The fecal concretions within the ap- 
pendix are now looked upon as of no importance whatever 
with regard to the causation of the disease, as they are also 
accidentally encountered in perfectly normal appendices. 
The opinion generally prevails that the inflammation is 
caused by micro-organisms which are conveyed to the in- 
terior of the organ in the fecal matter. According to 
Nothnagel, however, fecal concretions play a prominent 
part in lesions leading to perforation of the appendix. 

Movable kidney has been assumed to be a predisposing 
factor in the development of appendicitis by Carl Beck 1 
and Edebohls. 2 The much greater frequency of movable 
kidney in the female and the comparative infrequency of 
appendicitis in the latter as compared with the male sex 
seems to speak somewhat against this view. 

Actinomycosis, tuberculous and typhoid ulcers are pre- 
disposing causes of the disease. Occlusion of the lumen of 
the appendix, either partial or complete, is likewise a pre- 
disposing factor. These occlusions may be the result of 
former inflammatory lesions, but are most frequently due 
to the retrograde changes which this organ is gradually 
undergoing in the process of evolution. According to Eib- 
bert 3 and Zuckerkandl, 4 the appendix is found obliterated 
in about twenty-five per cent of all living persons. Both 
these writers ascribe this condition not to inflammatory 
diseases, but to the progress of evolution which takes place 
in the appendix. This view is supported by the fact that 

1 Carl Beck: "Appendicitis." Volkmann's Samralung klinischer 
Vortrage, No. 221, Leipzig, 1898. 

2 George M. Edebohls: Medical Record, 1898. 

3 Eibbert: "Beitrage zur norraalen und pathologischen Anatomie 
des Wurmfortsatzes. " Virch. Arch. , Bd. 132. 

4 E. Zuckerkandl : " Ueber die Obliteration des Wurmfortsatzes beim 
-Menschen, " Wiesbaden, 1894. 



APPENDICITIS. 20o 

obliteration of the appendix is found with gradually in- 
creasing frequency in more advanced age. Thus Kibbert 
found obliteration of the appendix in fifty per cent of per- 
sons above sixty years of age. 

Why the appendix should be the seat of disease so very 
much more frequently than other parts of the intestine is 
a question which cannot be so easily answered. The fact 
that the appendix is a rudimentary organ in which proc- 
esses of evolution are even normally discoverable makes it 
probable that it is imbued with less resistance against dis- 
ease-producing agents. The comparatively narrow lumen 
of the appendix and Gerlach's valve make the emptying of 
this little canal a difficult matter. This, in connection with 
the scantiness of circular muscular fibres in the walls of 
the appendix explains the slowness with which substances 
within the appendicular cavity are emptied into the intes- 
tine. Stagnation of contents in this organ is certainly a 
predisposing factor for disease. The abundance of ade- 
noid tissue in the appendix has been believed by some 
writers to be a predisposing cause of disease. Bacterial 
infections here take place in a similar manner as in the 
tonsils, and Sahli speaks by way of comparison of an an- 
gina of the appendix. Fowler and Van Cott ' believe that 
the vascular arrangement of the appendix (scantiness of 
blood supply, the main vessels being almost end arteries) 
is responsible to a great extent for the frequency of dis- 
ease in this organ. Some of the blood-vessels and nerves 
are primarily affected, and the nutrition of the appendix 
being thus disturbed, diseases of an infective character 
easily take place. Another predisposing cause of appen- 
dicitis is displacement and malformation of the appendix. 

While all the above-mentioned factors may predispose 
1 Van Cott-Fowler : "Treatise on Appendicitis." 



206 DISEASES OF THE INTESTINES. 

the appendix to disease, the real cause of the latter must 
be looked for in a bacterial invasion. Talamon was the 
first to lay stress upon the importance of microbes in ap- 
pendicitis. Nowadays all writers coincide with this view. 
Thus Tavel, 1 Hodenpyl, 2 Fowler, Wilson, 3 Barbacci, 4 and 
others ascribe a very important part to the bacillus coli 
communis (Escherich), which is almost always encoun- 
tered in lesions of the appendix, either in the exudate, pus, 
or the walls of the appendix itself. Other micro-organ- 
isms are, however, frequently found either in connection 
with the bacterium coli commune or alone. Thus strepto- 
coccus pyogenes, pneumococcus, staphylococcus pyogenes 
aureus, bacterium lactis, bacillus pyocyaneus and pyogenes 
foetidus, proteus vulgaris, and others have been encoun- 
tered. In most cases probably a mixed infection (several 
varieties of micro-organisms) takes place. The bacterium 
coli commune, however, is most frequently found, as it has 
a greater resisting-power and in the course of its growth 
usually causes disappearance of the other micro-organ- 
isms. 

Sex and age seem to play an important part in regard to 
the distribution of the disease. The male sex is much more 
frequently affected than the female. Thus, 

Sonnenburg reports 130 cases — 77 males, 53 females. 

Rotter " 68 " — 44 " 24 

Nothnagel " 130 " —105 " 25 

Bamberger 5 " 73 " — 54 " 19 

1 Tavel und Lanz : " Ueber die Aetiologie der Peritonitis. " Mitthei- 
lungen aus Kliniken und Instituten der Schweiz, Basel, 1893. 

2 Hodenpyl : " On the Etiology of Appendicitis. " New York Medi- 
cal Journal, 1893. 

3 E. Wilson : Cited after Fowler. 

4 Barbacci : Lo sperimentale, 1893, fasc. 4. 

5 Bamberger : "Die Entziindungen der rechten Fossa iliaca. " 
Wiener med. Wochenschr., 1853. 



APPENDICITIS. 



207 



Volz * reports 59 cases— 45 males, 14 females. 

Matterstock 2 " 1,030 « —733 " 297 

This preponderance of the male sex is already found in 
early life. Thus Matterstock observed 72 cases of appen- 
dicitis in early life (seven months to fifteen years), and 
among this number were 51 male children and 21 girls. 
The greater frequency of appendicitis in the male sex is 
explained bj Van Cott as due to the circumstance that the 
appendix of the male has a less abundant blood supply 
than that of the female ; for in the latter there is a col- 
lateral circulation derived from the sexual apparatus. 

With regard to age all writers agree that appendicitis is 
most frequently encountered between the tenth and thir- 
tieth years. It occurs less frequently in the first decade 
of life and in the thirtieth to fortieth years, and is quite 
rare in advanced age. The following table is submitted 
with a view of showing the frequency of appendicitis in 
the different decades of life as recorded by several eminent 
writers : 



Ages. 


Fitz. 


Matterstock. 


Nothnagel. 


Total number 


228 

22 

86 

65 

34 

8 

11 

1 

1 


474 

46 
143 

158 

72 

30 

18 

5 

2 


129 


1 to 10 


1 


10 to 20 


44 


20 to 30 


57 


30 to 40 


14 


40 to 50 


7 


50 to 60 


4 


60 to 70 


2 


70 to 80 










The frequency of appendicitis in relation to other dis- 
eases can be studied from the report of the autopsies made 

1 Ad. Yolz : " Die durch Kotbsteine bedingte Perforation des Wurm- 
fortsatzes, etc. , " Karlsrube, 1846. 

'-Matterstock: "Perityphlitis. " Gerkardt's Handbuch der Kinder- 
krank., Tubingen, 1880. 



208 DISEASES OF THE INTESTINES. 

in the pathological institute of the Wiener Allgemeine 
Krankenhaus between 1870 and 1896. According to Noth- 
nagel, the total number of autopsies was 44,940. Among 
these the number of cases dying from appendicitis amounted 
to 148. The percentage of appendicitis, therefore, was 
0.32. With regard to sex there were 107 males (72.3 per 
cent) and 41 females (27.7 per cent). The actual fre- 
quency of appendicitis among the living, however, is much 
greater than appears from these numbers, which relate 
only to cases which have resulted fatally. 

Morbid Anatomy. — The pathological anatomy of appen- 
dicitis has been thoroughly studied recently, not only in 
autopsies but principally in operative cases. In the latter 
an insight is permitted into the changes which take place 
early in the disease. Fowler distinguishes four stages of 
anatomical lesions according to the spread of the morbid 
process involving the different tissues of the appendix. In 
the first stage (endo-appendicitis) more or less intense in- 
flammation of the mucous and submucous layers takes 
place. The second stage (parietal appendicitis) consists 
in an inflammatory process involving the interstitial or 
intermuscular structure of the body of the appendix. The 
third stage (peri-appendicitis) means an inflammatory proc- 
ess involving all the layers of the appendix, the peritoneum 
included. The fourth stage (para-appendicitis) consists in 
lesions involving the appendix and the neighboring tissues. 
This process is most often accompanied with suppurative 
inflammations of the connective tissue adjacent to that por- 
tion of the appendix which is not covered with perito- 
neum. 

According to Fowler, the above described stages are not 
essentially different processes but further developments of 
one and the same lesion. 



APPENDICITIS. 209 

Riedel, 1 Notlmagel, and others distinguish two different 
types of appendicitis which are of great clinical importance. 
They are the following : 

1. Catarrhal appendicitis (enclo-appendicitis) . Here in the 
acute form the mucosa of the appendix is swollen and red- 
dened, the submucosa is engorged and filled with round 
cells. The follicles are distinctly swollen. The appendix 
appears swollen and more rigid, and its lumen is filled with 
thick yellowish contents, mostly mucus; sometimes the 
latter may be mixed with fecal matter. Occasionally there 
are fecal concretions. Often ecchymoses of the mucosa 
occur, leading sometimes to superficial defects (erosions) . 
All these lesions may entirely disappear after the acute at- 
tack is over, and thus a perfect cure may be established. 
This, however, is possible only if there is no occlusion of 
the lumen of the appendix and the inflammatory products 
can be emptied into the caecum. 

In the large majority of cases of catarrhal appendicitis 
the cure is not a perfect one and chronic appendicitis is 
the result. In this stage the mucosa of the appendix 
presents a slate-gray appearance. It is filled with accumu- 
lations of round cells; at the same time proliferation of 
connective tissue and occasionally blood pigment are found. 
The submucosa and muscularis may show no changes 
whatever, although as a rule they are hypertrophied. The 
latter condition is probably due to stricture of the lumen 
of the appendix and consecutive muscular (compensatory) 
hypertrophy. The chronic form of appendicitis, owing to 
suppurative processes of the mucous membrane, occasion- 
ally leads to a total destruction of the mucosa, and an ob- 
literation of the lumen of the appendix. This condition is 

1 Riedel : " Ueber die Friihoperation bei Appendicitis purulenta seu 
gangraenosa." Berl. klin. Wochenschr. , 1899, Nos. 33 and 34. 
14 



210 DISEASES OF THE INTESTINES. 

very similar to obliteration of the lumen due to the involu- 
tion processes which have been mentioned above. The 
appendix then forms a solid membranous band of uniform 
thickness or with a few small protrusions. As a rule it is 
found embedded in peritonitic adhesions. 

Sometimes primary slight lesions of the appendix lead 
to complications, especially if a stricture is present. Thus 
an accumulation of secretion within the occluded appen- 
dicular cavity may take place and give rise to the forma- 
tion of a cyst. Such cysts occur, varying in size from a 
cherry to a fist. Guttmann 1 observed a cyst of the appen- 
dix fourteen centimetres (five and a half inches) long and 
twenty-one centimetres (eight and a quarter inches) wide. 
The contents of such a cyst are either of a watery mucous 
character or gelatinous. 

If ulceration takes place in the occluded appendicular 
cavity, it may give rise to the formation of a small abscess 
(py-appendix or empyema processus vermiformis). In 
these cases the purulent process may penetrate the wall 
of the appendix and lead to perforation. A timely opera- 
tion in many instances prevents such an outcome. 

2. The severe form of appendicitis {appendicitis ulcerosa 
et gangrenosa, appendicitis perforative:). In this group 
the bacterial infection is of a much more virulent nature 
than in the catarrhal form. The inflammation originating 
in the mucosa of the appendix at once involves all its lay- 
ers, including the serosa. Necrobiotic processes and for- 
mation of pus take place quite early. The peritoneum is 
also very soon involved, either in the immediate neighbor- 
hood of the appendix or in its entirety. Ulcerations and 
gangrenous processes may lead to the destruction of a 

1 P. Guttmann : Verhandlungen des Vereins fiir innere Medicin zu 
Berlin, 1883-84, p. 301. 



APPENDICITIS. 211 

part of the appendix, thus causing perforation, or to a total 
necrosis of the entire appendix. As a result of this proc- 
ess the latter may be cast off from the csecum and be found 
free in the peritoneal cavity or embedded in pus. 

The way in which the peritoneum is involved is quite 
variable. There may be an adhesive type of peritonitis 
leading to a matted and agglutinated condition of the ap- 
pendix, or a circumscribed or diffuse peritonitis without 
adhesions. The contents of the appendix may be emptied 
into the abdominal cavity or hemmed in by adhesions. 
The size, location, and direction of the abscess differ 
greatly. The location and length of the appendix and the 
portion perforated play an important part in this respect. 
In the great majority of cases the abscess is at first intra- 
peritoneal, but very soon extends toward the surface or 
above or below Poupart's ligament. Again it may pene- 
trate into the bladder, vagina, small intestine, or rectum. 
In some instances it reaches the diaphragm and from 
there perforates into the pleural cavity. 

In some very grave cases there is no abscess but a dif- 
fuse peritonitis. Here we often meet with a paretic con- 
dition of the intestine, the latter being filled with gas ; the 
serous layer is shiny and red, while there is an absence of 
any exudation. In other cases a small quantity of a purely 
serous or bloody serous exudation is found. The condi- 
tion just described may be discovered either in operations 
undertaken very early or at autopsies in cases which ter- 
minate fatally at the beginning of the disease. In still an- 
other group of cases which is a comparatively very small 
one, the general peritonitis inay assume a more protracted 
and chronic form. In these cases mattings and adhesions 
are formed over more or less large areas of the abdominal 
cavity, and in these accumulations of pus may be found. 



212 DISEASES OF THE INTESTINES. 

Appendicitis due to tuberculosis is of comparatively rare 
occurrence and shows a great tendency to the formation of 
nstulse. Eecently actinomycosis has been found to be the 
cause of some cases of appendicitis with the formation of 
abscesses. In these cases the actinomycosis fungi can 
easily be demonstrated. 

Symptomatology . — In describing the symptomatology of 
appendicitis it will again be best to differentiate the two 
forms already mentioned above, namely, the catarrhal and 
the severe form. 

1. Catarrhal or endo-appendicitis. An attack of appendi- 
citis is usually characterized by a sudden appearance of 
pain iu the abdominal cavity, which at first may be dif- 
fused or. in the region of the navel, but very soon is local- 
ized in the right iliac region. A moderate rise of temper- 
ature is very frequently present. Slight gastric symptoms, 
nausea, and sometimes vomiting often occur, but are, as a 
rule, only transient. The pains usually increase in inten- 
sity, and the patient assumes a fixed position with the legs 
flexed. Any change in the position or any movement of 
the thighs increases the pain. Examination by palpation 
shows extreme tenderness on pressure of the right iliac re- 
gion, more especially at McBurney's point, while the rest 
of the abdomen can be examined by pressure without giv- 
ing rise to the slightest pain. While the pains are gener- 
ally continuous, they may show periods of exacerbation. 
The latter, according to Nothnagel, are most probably due 
to a spastic contraction of the muscles of the appendix. 

The term "appendicular colic" has been given by Tala- 
mon to the same condition. Talamon, however, assumed 
that the colic is always due to an attempt of the appendix 
to rid itself of a fecal concretion. Inasmuch as operations 
for appendicitis have often been performed during the at- 



APPENDICITIS. 213 

tack of colic and no fecal concretions whatever found iu 
the appendix, and inasmuch as coproliths have been found 
in cases in which no colic whatever existed, this theory 
cannot be maintained. 

In some cases there is an area of resistance in the right 
iliac region. If the latter be due to an accumulation of 
fecal matter in the caecum, the tumor can be slightly moved 
and its shape changed by pressure. In a few of the cases 
of catarrhal appendicitis the resistance is due to an inflam- 
matory swollen (serous) condition of the appendix and of 
the neighboring organs. In this instance the tumor is not 
circumscribed but rather diffuse, immovable, and its shape 
unaffected by pressure. 

In comparatively few cases can the appendix be directly 
palpated. It then appears as an elongated round body of 
the size of the little finger, and is very painful on pressure. 
The examination of the appendix itself, whenever this is 
possible, is certainly of the utmost importance for diagno- 
sis. Edebohls ' deserves much credit for having cultivated 
and perfected the method of examining the appendix by 
palpation. According to Edebohls, this examination is best 
done as follows : The patient lies upon his back with the 
legs comfortably flexed. The physician standing at the 
patient's right begins to search for the appendix by apply- 
ing two, three, or four fingers of his right hand, palmar 
surface downward, almost flatly upon the abdomen at or 
near the umbilicus ; while now he draws the examining fin- 
gers over the abdomen in a straight line from the umbili- 
cus to the anterior superior spine of the right ilium, he 
notes successively the character of the various structures 
as they come beneath and escape from the ringers passing 
over them. In doing this the pressure exerted must be 

1 Edebohls : American Journal of the Medical Sciences, May, 1894. 



214 DISEASES OF THE INTESTINES. 

strong enough to recognize distinctly along the whole 
route traversed by the examining fingers the resistant sur- 
face of the posterior abdominal wall and of the pelvic brim. 
Only in this way can we positively feel the normal or 
slightly enlarged appendix. Pressure short of this must 
necessarily fail. 

K. T. Morris ' suggests for Edebohls' method of palpating 
the use of three right-hand fingers to feel with and three 
left-hand fingers placed upon these to press with. The 
fingers that are to do the feeling are pressed by means of 
the three others down to the border of the right rectus ab- 
dominalis muscle at the level of the navel and slowly drawn 
toward the examiner. I have found both these methods 
very useful in detecting the position and size of the ap- 
pendix. 

The temperature is usually but slightly raised, some- 
times even normal. The pulse likewise is either normal 
or but moderately accelerated. 

Constipation is often present, but seems to be rather the 
result of the inflammatory condition of the appendix than 
its cause, as was formerly believed. In a comparatively 
small number of cases diarrhoea is present during the at- 
tack of appendicitis. 

Course. — An acute attack of catarrhal appendicitis may 
last from two to three days to two to three weeks. After 
this variable period of sickness the symptoms either en- 
tirely disappear or persist in a slight degree. With regard 
to the further development the following classes must be 
distinguished: 1. There may be complete recovery without 
any further trouble. 2. The patient may entirely recover 
from the present attack, but have a return of the disease 
after a variable period of time (from a few weeks, a few 

1 R. T. Morris : "Lectures on Appendicitis," New York, 1899, p. 45. 



APPENDICITIS. 215 

months to a year or two) — "recurrent appendicitis." 3. 
The symptoms may not completely disappear but may 
persist for many weeks and the patient may remain in a 
lingering condition — "subacute or chronic appendicitis." 

The first class of perfect recoveries is comparatively small. 
In this group there is either an obliteration of the appen- 
dix or the catarrhal process may have subsided completely 
without having left behind any lesions. The second class 
of recurrent appendicitis comprises the majority of the 
cases. In these a chronic catarrhal condition of the mu- 
cosa of the appendix may persist without manifesting 
symptoms until a new invasion of micro-organisms gives 
rise to an acute exacerbation of the process, or strictures 
of the lumen of the appendix may have formed as a conse- 
quence of the acute attack and thus become the cause of 
renewed disturbances later on. In the third category the 
catarrhal appendicitis has led to severe anatomical lesions. 
There may be a considerable thickening of the appendix 
wall including the serosa. The appendicular lumen may 
show ulcerations, strictures, or bends. There may also 
be an accumulation of pus (py-appendix) . The second 
and third varieties may exist without manifesting distinct 
symptoms of the appendicular lesion, the patients com- 
plaining merely of manifold digestive disturbances (appen- 
dicitis larvata of Ewald '). 

2. The severe form of appendicitis (appendicitis suppura- 
tiva or perforans). The disease usually begins quite sud- 
denly in the midst of perfect health ; rarely it is preceded 
by slight digestive disturbances. The patient is seized with 
violent pains in the abdomen. These are felt at first either 
over the entire abdomen, in the epigastric region, or on 

1 C. A. Ewald : " Krankheiten des Darmes und Bauclii'ells " Berlin 
1902, p. 226. 



216 DISEASES OF THE INTESTINES. 

the left side of the abdomen, but very soon they settle in 
the right iliac region. The pains are of an intense charac- 
ter, and occasionally are accompanied by paroxysms dur- 
ing which they are almost unbearable. Any motion in- 
creases the pain. The patient lies perfectly motionless 
and breathes superficially. The appearance is that of a 
very sick person, the countenance manifests great suffer- 
ing and anxiety. The temperature is usually considerably 
increased and continues so during the first days of the dis- 
ease. The pulse is accelerated. Occasionally it is of 
small calibre, easily compressible, and at times irregular. 
The latter phenomena are found principally in critical 
conditions. A very frequent pulse and a comparatively 
low degree of fever are also considered bad omens. There 
is always complete anorexia and great thirst, the tongue 
is dry and thickly coated, the bowels, as a rule, are con- 
stipated. In rare instances there is diarrhoea. Accord- 
ing to Nothnagel, vomiting is present in almost three- 
quarters of the cases. It usually appears right at the 
commencement of the disease and lasts only a short time. 
In exceptional instances it persists for several days. The 
vomited matter consists of gastric contents, mucus, and 
bile. In very grave cases it exceptionally assumes a fecu- 
lent character. The vomiting is occasionally accompanied 
by hiccoughs. Beth these phenomena are very annoying 
and at the same time increase the pain through the mo- 
tions evoked by them. 

In many of the cases, soon after the commencement of 
the disease a tumor begins to form in the right iliac re- 
gion. At first a rigidity of the muscles in this region is 
noted; later on a distinct resistance over an area of egg 
size may be found. The tumor is either circumscribed 
and sharply defined, or it is diffuse and connected with 
the neighboring tissues. The skin over the tumor is as 



APPENDICITIS. 217 

a rule easily movable, while the latter is immovable. The 
tumor generally consists of a purulent exudation in and 
around the appendix and congested portions of the intes- 
tines, occasionally of the omentum, and of a purulent infil- 
tration of the abdominal wall itself. In some instances 
the size of the tumor is considerably increased by an ac- 
cumulation of fecal matter in the caecum. The tumor may 
be discovered by palpation and sometimes by percussion. 
Fluctuation is present only in very extensive abscesses. 
Its absence does not signify the absence of pus. The re- 
sistance as a rule increases either very slowly or quite 
rapidly. In rare instances, namely in those in which the 
abscess is surrounded by a firm capsule, it may remain 
unchanged for a long time. The abscess occasionally in- 
volves the muscles and even the skin lying above it. The 
latter becomes infiltrated and cedematous, and in rare in- 
stances the abscess may spontaneously open through the 
skin. Occasionally the resistance disappears entirely when 
the purulent exudation has descended into the deeper parts. 
In such an event, by an examination through the rectum, 
and in females through the vagina, the exudation may be 
discovered filling Douglas' space. 

In cases in which there is an extensive inflammation of 
the peritoneum accompanied by a considerable quantity of 
pus, severe pains in urination appear quite early, after two 
or three days (Fleischer). On this account the patients are 
often rather afraid to urinate. In the same cases there 
may also be paresthesia and anaesthesia in the limbs, or 
obstinate erections of the penis, or a drawing up of the 
right testicle. These symptoms all show that the accumu- 
lation of pus presses upon the nerves of the sacral plexus. 

The further course of the disease will largely depend 
upon the way in which the newly formed pus around the 
appendix acts. Often it leads to a perforation of the ap- 



218 DISEASES OF THE INTESTINES. 

pendix. Sometimes the abscess forms adhesions and is 
encapsuled. Sometimes, again, the abscess penetrates into 
the peritoneal cavity and gives rise to diffuse septic or 
flbrino-purulent peritonitis. 

Perforation of the appendix which occurs quite fre- 
quently in this class of cases is accompanied, according 
to Sonnenburg, by the following symptoms: The disease 
begins with febrile and marked symptoms; violent pains 
in the abdomen appearing either suddenly or after a short 
period of slight uneasiness and concentrating very quickly 
in the right side ; vomiting accompanied by diarrhoea and 
in other cases by constipation ; small and frequent pulse ; 
fever commencing with chills and quickly rising; pro- 
nounced tympanites; general appearance extremely bad; 
slight cyanosis and perspiration ; a distinct area of resist- 
ance over or around the affected spot. "While all these 
symptoms are certainly found in cases of perforation of 
the appendix, they can by no means be absolutely relied 
upon ; for they may exist in the same manner without a 
perforation taking place, and, on the other hand, the lat- 
ter event may occur without any of the above-mentioned 
symptoms being present. For these reasons Boas 1 is re- 
luctant to make the diagnosis of perforative appendicitis, 
and contents himself with determining the presence of 
purulent appendicitis. 

Perforation peritonitis most often appears between the 
second and fourth days of the disease (Fitz). The danger 
of a penetration of pus into the free peritoneal cavity less- 
ens with the length of time the disease has lasted, on ac- 
count of the formation of adhesions. On the other hand, 
numerous other perilous events may take place. In some 
cases a few days after the commencement of the disease 

1 J. Boas : " Diagnostik und Therapie der Darmkrankheiten, " Leip- 
zig, 1899. 



APPENDICITIS. 219 

there is a subsidence of the most important symptoms 
(pains, fever, etc.), while in others they persist with undi- 
minished severity. Even in the first class, however, the 
amelioration rarely persists, for pretty soon afterward the 
pains reappear and the fever recurs, and in connection 
with these symptoms the inflammation increases and the 
pus augments. Periods of improvement and exacerbation 
of the condition may alternate for quite a while until at 
last either recovery or a fatal issue ensues. 

A spontaneous cure or recovery without surgical inter- 
vention may occur in one of the following ways : 

1. The abscess may become encapsulated, the pus losing 
its virulence and becoming absorbed. In such an event the 
tumor disappears and the patient is either definitely or ap- 
parently cured ; for dangers to life remain after such a cure 
in consequence of the remnants of the abscess and of the 
adhesions formed among the intestines. " The occurrence 
of a sudden bursting of the abscess," using Ewald's words, 
" hangs like the sword of Damocles over the head of the 
patient as long as there is still pus present." In seemingly 
perfect health a fatal peritonitis may thus occur in patients 
who had previously suffered from an attack of appendicitis. 

2. A cure may be established by the opening of the 
abscess into adjacent hollow viscera. Thus the abscess 
may open into the caecum, colon, small intestine, bladder, 
vagina, or pelvis of the kidney. This favorable issue is, 
however, rare. 

3. The abscess may find its way externally by ruptur- 
ing spontaneously through the skin. Sometimes, however, 
the pus burrows into other organs ; thus it may reach the 
diaphragm (subphrenic abscess), and sometimes even force 
its way through into the pleural cavity and perhaps the 
lungs. But even from these places the pus may be evacu* 



220 DISEASES OF THE INTESTINES. 

ated spontaneously, principally through rupture into a 
bronchus and its expulsion during a coughing spell. 

In a large number of cases peritonitis and septicaemia 
terminate the life of the patient ; in others after recovery 
there are frequently grave recurrences of the disease. 

Diagnosis. — Catarrhal appendicitis can be diagnosed if 
there is a sudden onset of pain in the right abdominal cav- 
ity, principally in the region of the appendix, combined 
usually with a slight rise of temperature and some light 
gastric symptoms (nausea, anorexia, vomiting). The 
grave form of the disease or purulent appendicitis shows 
the same manifestations, only of a much, severer type. 
Besides there are always present signs of serious illness. 
The patient is very pale and manifests an anxious ap- 
pearance. Chills are frequently present and the tempera- 
ture shows a certain irregularity in its course. There may 
be a marked rise in temperature after it has been quite 
low or almost normal for a time. 

The presence of a tumor in the right iliac region is of 
great importance in the diagnosis of appendicitis, although 
this symptom is frequently absent. In order to recognize 
the nature of the tumor with regard to its contents, espe- 
cially whether pus is present or not, Sahli first suggested 
the use of an exploratory puncture. If pus can be aspi- 
rated through the needle, then an abscess is positively 
present. Although many physicians make use of this 
method even nowadays, as for instance Ley den, 1 Noth- 
nagel, Penzoldt, 2 Fleischer, Boas, and others, most of the 
surgeons are decidedly opposed to this diagnostic measure 
(Fowler, Treves, 3 Sonnenburg, and others). In this coun- 

] E. vonLeyden: Berl. klin. Wochenschr., 1889, No. 31. 

2 Penzoldt: "Behandlung der Erkrankungen des Darms." Pen- 
zoldt- Stintzing's "Handbucii der speciellen Therapie innerer Krank- 
heiten, " Jena, 1896. 

3 Treves: "On Peritonitis." British Medical Journal, 1894. 



APPENDICITIS. 221 

try the consensus of opinion is against the use of explora- 
tory puncture, for its employment adds a new element of 
danger to the case, while its results, especially if negative, 
are unreliable. 

While appendicitis can usually be diagnosed without 
difficulty, in some instances its recognition is quite diffi- 
cult. In cases in which the appendix is abnormally situ- 
ated, as for instance in the left iliac region or in the upper 
part of the right abdominal cavity, the diagnosis of appen- 
dicitis will hardly be possible. 

Differential Diagnosis. — The following conditions may at 
times be confounded with appendicitis, namely, biliary, 
renal, and intestinal colic. The following points will serve 
as a guide in making a correct diagnosis. In biliary colic 
the pains are referred by the patient to the right abdominal 
cavity, radiating to the back and up to the shoulders. Pal- 
pation shows a painful area situated immediately below the 
right margin of the ribs ; occasionally jaundice is present. 
In kidney colic (right side) the pain is felt by the patient 
in the right lumbar region, radiating toward the bladder. 
There is generally a frequent desire for micturition and 
slight burning in the urethra. The urine may show the 
presence of mucus, sometimes of blood and pus cells. In 
intestinal colic the pain may be referred to the right iliac 
region, but, as a rule, it is relieved very soon after the 
passage of flatus. In contradistinction to these three con- 
ditions the pain in appendicitis is referred to the right 
iliac region, where it remains localized, does not disappear 
upon passage of flatus, does not radiate to the shoulder 
and but very rarely to the bladder, while there is also great 
tenderness and pain upon pressure at McBurney's point. 
No jaundice is present and the urine is normal. 

In women the differential diagnosis between appendici- 
tis and a right-sided salpingitis is not always easily made. 



222 DISEASES OF THE INTESTINES. 

A thorough examination through the vagina, however, will 
in most instances enable us to decide as to the true condi- 
tion. If the appendix is situated in the small pelvis and 
has given rise to the formation of an abscess in this local- 
ity the decision of the question whether the abscess is 
due to appendicitis or to oophoritis is extremely difficult 
and sometimes even impossible. Typhoid fever in ex- 
ceptional cases may simulate an appendicitis; the pres- 
ence or absence of Widal's reaction will serve to differ- 
entiate the former. 

Prognosis. — Catarrhal appendicitis affords in most in- 
stances a favorable prognosis as regaids to life. With ref- 
erence to complete recovery, however, the outlook is by no 
means bright, for the liability to recurrence of the disease 
is very great. Inasmuch as an apparently mild form of 
appendicitis may all of a sudden change its character and 
assume alarming features, the prognosis should always be 
made with a certain reserve, even in this class. 

The purulent form of appendicitis must be regarded 
as a very serious disease and gives quite an unfavorable 
prognosis unless timely surgical intervention is adopted. 
The intensity of the symptoms in purulent appendicitis is 
by no means a correct measure of the gravity of the dis- 
ease. Experience shows that cases with violent symp- 
toms, very high fever, and intense pains, etc., occasionally 
recover within a few days, the pus rupturing into the intes- 
tine, while apparently mild cases after a few days of sick- 
ness suddenly develop symptoms of a general septic peri- 
tonitis with a fatal issue. Diffuse peritonitis is liable to 
occur between the second and fourth days of sickness, but 
even later the patient is subjected to numerous risks. 
Grave complications may suddenly develop even in a pa- 
tient who is apparently progressing nicely and already 
convalescent. Thus purulent appendicitis may give rise 



APPENDICITIS. 223 

to pyopneumothorax, empyema, or purulent pericarditis, 
and these complications may result in a fatal issue. The 
prognosis of perforating appendicitis is decidedly less fa- 
Torable than that of a simple empyema of the appendix, 
as in the former septicaemia is liable to occur. 

After having described the numerous dangers present in 
the severe form of appendicitis it is consoling to say that 
spontaneous recoveries are, notwithstanding this, in the 
majority. With regard to the frequency of spontaneous 
recoveries Nothnagel gives the following statistics : Among 
130 hospital patients he observed 85 complete recoveries, 
4 deaths without operation, 30 partial recoveries, and 11 
cures after operation. The large number of cases reported 
by Sahli is also very important in this connection. This 
author reports the results in 7,213 cases of appendicitis; 
473 cases were operated upon, while 6,740 received only 
medical treatment. Among the latter 6,194 recovered (91.2 
per cent) while 591 (8.8 per cent) died. Sahli further 
states that of the 4,593 cases which had not been operated 
upon and in which inquiries had been made with regard 
to recurrence of appendicitis, 3,635 were cured without 
any recurrence. 

Nothnagel says that circumscribed appendicitis is cura- 
ble in the large majority of cases, and that about eighty 
per cent recover under simple medical treatment. Among 
the rest there are still some that can be cured by means 
of operative procedures. Careful watching of the pa- 
tient and timely surgical intervention in proper cases 
may reduce the number of deaths from appendicitis to 
perhaps five per cent or three per cent. It is, however, 
impossible entirely to avoid fatal issues, even with the 
greatest and strictest watchfulness. Aside from accidental 
complications and from rare cases in which a correct diag- 
nosis is hardly to be made, there remain instances in which 



224 DISEASES OF THE INTESTINES. 

the peritoneum is diffusely affected quite early without 
presenting any symptoms. These are the cases which 
make the prognosis unfavorable and they form the great- 
est contingent of deaths among patients with appendicitis. 
The acute septic form with perforation of the appendix is 
the most dangerous, while the progressive suppurative form 
is comparatively favorable. 

Treatment. — With reference to prophylaxis the swallow- 
ing of fruit pits, of very small bones, and coarse, indi- 
gestible matter in the food was formerly strictly forbidden. 
Nowadays, however, we> know that the above-named sub- 
stances play no part whatever in the etiology of appendi- 
citis. Regulation of the bowels or, more practically speak- 
ing, correcting constipation has been believed to be of 
importance in preventing appendicitis. This maxim can 
likewise not be maintained on the ground of recent re- 
searches. Regularity of the bowels is in itself of impor- 
tance, and hence it will be advisable to pay attention to 
this factor. The only means we possess of preventing an 
attack of appendicitis is the removal of the appendix. 
While this suggestion is not generally practicable, for it 
requires an operation which is not entirely without risk, 
it may, however, be carried out in cases requiring a lap- 
arotomy for other diseases, provided that this additional 
operation does not demand too much time. 

The medical treatment of appendicitis consists in abso- 
lute rest of the entire body, especially of the intestinal 
tract, and in appropriate diet. The patient must be kept 
strictly abed from the commencement of the disease until 
it is entirely over. He should not be permitted to leave 
the bed for a moment. He must lie perfectly quiet ; even 
turning from one side to the other should be avoided, or if 
done, performed with the greatest care. In taking nour- 



APPENDICITIS. 225 

ishment the liead may be slightly raised ; the urine should 
be voided in a glass, and an evacuation of the bowels 
should take place in a bed-pan. During this act the pa- 
tient must be forbidden to strain or exert himself in any 
way. The utensils needed must be handled by the nurse, 
who must also attend to the cleansing of the patient. 

The principle of rest must also be applied with reference 
to diet. During the first few days of illness there should 
be either total abstinence from food (only small quantities 
of water being given now and then), or liquid food in small 
portions. Thus strained barley water, or this with the 
addition of a little milk, oatmeal water and rice water 
given in the same way, chicken soup, very weak tea. In 
the very severe forms of appendicitis, especially when per- 
foration has taken place, or when symptoms of ileus and 
fecal vomiting are present, absolute abstinence from food 
and also drink is necessary. In accordance with Penzoldt, 
Ewald, and Boas, rectal feeding appears to me to be con- 
traindicated in these cases and the only way of supplying 
the organism with nutritive material is a subcutaneous 
injection of saline solutions, sugar solutions, and also per- 
haps small subcutaneous injections of olive oil. 

Small pieces of ice may from time to time be given to 
the patient. He must, however, keep the ice in his mouth 
until it melts before swallowing. This often alleA T iates the 
nausea and retching. The first two or three days of sick- 
ness being over, the patient may be allowed to have milk, an 
egg beaten up in bouillon or milk, in addition to the above- 
named food. The diet should be kept up in this way until 
the pains and fever have entirely disappeared. At this pe- 
riod soft-boiled eggs, crackers, small portions of meat 
(squab) or chopped beef may be given, and still later mashed 
potatoes, bread and butter, and light vegetables added. 



226 DISEASES OF THE INTESTINES. 

Medicaments. The use of cathartics is mentioned here 
only in order to condemn it. Even injections into the 
bowels should not be administered too frequently nor in 
large quantities. A small enema of one-half to one pint of 
water or one-half pint of olive oil may occasionally be given. 

The remedy par excellence in the treatment of appendici- 
tis is opium. Its use was originally recommended by Eng- 
lish physicians (Graves, Stokes) and later by French clin- 
icians (Petriquin, Grisolle); in Germany this remedy 
found a fervent advocate in Volz and in America in Alonzo 
Clark. During the last decade the administration of opium 
has met with great opposition especially on the part of many 
surgeons. Their reasons against the use of this remedy are, 
first, that opium masks the true picture of the disease, and 
secondly, that it gives rise to paralysis of the intestines. 

Some of the foremost clinicians, Nothnagel, Penzoldt, 
Ewald, Sahli, Boas, and others, are even nowadays en- 
thusiastic admirers of the opium treatment. The prin- 
cipal element of importance of opium as a remedy is its 
action in lessening or arresting the peristalsis of the in- 
testine, and besides in alleviating pain. I myself have 
always used and still use the opium treatment with great 
satisfaction. It is of course understood that the opium 
should be given only in sufficient amount to allay the pain, 
while excessive doses should be avoided. As soon as the 
active stage of the disease is passed, the opium must be 
entirely discontinued. The best way of administering it 
is that suggested by Sahli . Ten or fifteen drops of tinc- 
ture of opium are at first given every hour until there is 
a decided subsidence of the pain. Then five to six drops 
are given every two or three hours until the pains disap- 
pear completely. As soon as there is an exacerbation an- 
other large dose is administered, but if the patient is entirely 



APPENDICITIS. 227 

free from pain no opium is given. If the administration 
of the drug excites nausea or vomiting, it may be given in 
the form of a suppository : 

3 Extr. opii 0. 05 

01. theobrom 1.00 

M. f. supp. One suppository every four hours until subsi- 
dence of pain. 

Or belladonna extract, 0.005-0.01 gin., may be added to 
the opium in the same suppository. 

Boas recommends the administration of opium subcuta- 
neously. (Extr. opii aquosi sterilis. 0.3 to 10.0 water; 1 
Pravaz syringe [1 gm.] three times daily.) 

In cases in which the pains are very intense and a quick 
action is desired, morphine may be administered subcuta- 
neous^ in doses of gr. \ to J. The action of this remedy 
is, however, not so satisfactory as that of opium, as it has 
but a very slight influence in diminishing the peristalsis. 
When morphine is used, opium should be given in addition. 

Poultices. The application of ice over the painful area 
is often beneficial at the beginning of the disease, espe- 
cially if the temperature is quite high and symptoms of 
peritoneal irritation are present. If the patient, however, 
complains of great discomfort from the application of ice, 
it must be discontinued. In the latter instance a cold 
Priessnitz poultice may be tried. Cases not accompanied 
by high fever often derive great relief from the application 
of a hot-water bag or plain warm poultices. The latter 
are especially to be recommended in that form of appendi- 
citis which is called appendicular colic of Talamon. 

Surgical Treatment. — The question of operation in ap- 
pendicitis is a very live one nowadays and is being every- 
where discussed. The medical profession has not yet come 
to a unanimous conclusion in regard to it. Surgical treat- 



228 DISEASES OF THE INTESTINES. 

ment of appendicitis originated in this country, Dr. Eegi- 
nald Fitz of Boston having done the first operation for 
this purpose, and it has been practised and perfected here 
more than anywhere else. It is therefore quite natural 
that we find many more advocates of surgical intervention in 
America than abroad. As a general rule the majority of sur- 
geons frequently recommend operative intervention, while 
the larger number of physicians reserve the surgical treat- 
meat only for a small number of grave cases of appendicitis. 
Fowler, Morris, Beck, Deaver, Murphy, and others in 
this country and Legueu ' in France urge surgical treat- 
ment in every case of appendicitis. Legueu says: "Ap- 
pendicitis belongs to surgery." . . . "There is no medi- 
cal treatment of appendicitis." . . . "Every appendicitis 
must be operated earlj-." C. Beck 2 expresses himself 
in the following manner: "No matter how mild the clini- 
cal picture of appendicitis appears, even if it promises a 
quick temporary recovery, the operation is always justi- 
fied. Inasmuch as the gravity of infection cau never be esti- 
mated at the beginning, it appears wiser to look upon every 
case of appendicitis as serious. Of two evils one should 
choose the lesser, and the lesser one here means opera- 
tion." In his article Beck makes the two following asser- 
tions : "1. Appendicitis is a surgical disease and should be 
treated surgically as soon as diagnosed. 2. So long as no 
physician is able to estimate the gravity of the bacterial 
infection at the commencement of the disease or to foresee 
the course which the appendicitis will pursue, whether 
mild or grave, the safest treatment consists in the early 
removal of the appendix." 

1 Felix Legueu: "Traitment de l'Appendicite. " Suite de Mono- 
graphies Cliniques, 1899, No. 80. 

2 C. Beck : "Appendicitis. " Volkmann's Sammlung klinischer Vor~ 
trage, No. 221, Sept... 1898. 



APPENDICITIS. 229 

Many surgeons, even in this country, however, do not 
take so radical a view as the above writers. Thus Willy 
Meyer, 1 Charles McBurney, W. T. Bull, A. J. McCosh and 
P. Hawkes, 2 and others do not recommend the early opera- 
tion in milder forms of appendicitis. McCosh and Hawkes 
express themselves in the following manner with regard to 
the necessity of operative interference : " When the presence 
of pus is assured, the sooner operation is done the better. 
Also there are cases which begin and continue for twenty- 
four or forty-eight hours with such severity that a judicious 
mind must conclude that operation is demanded. So in the 
chronic and relapsing cases where the symptoms have con- 
tinued for months with such severity and have recurred 
so frequently as to subject the patient to a life of semi-in- 
validism, no wise surgeon can counsel any other plan of 
treatment than removal of the diseased appendix. Likewise 
when the patient has suffered from three or more attacks 
the offending organ should be removed, for other attacks 
will in all probability follow. The same indication for 
operation also exists in our opinion if a patient has suf- 
fered from two attacks within a year or even two years." 
..." The view which we take is that operation is not 
necessary in every case of appendicitis. We believe that 
not infrequently patients recover, and recover permanently, 
from one attack of appendicitis, and that in a certain num- 
ber of cases, provided a careful watch is kept, operation is 
not necessary. On the other hand, we acknowledge that 
many cases which did not appear to be serious have been 
allowed to die when they might have been saved by opera- 
tion." 

1 Willy Meyer : " When Shall we Operate for Appendicitis? " Medi- 
cal Record, February 29. 1896. 

2 A. J. McCosh and F. Hawkes : " The Surgical Treatment for Appen- 
dicitis." The American Journal of the Medical Sciences, May, 1897. 



230 DISEASES OF THE INTESTINES. 

Willy Meyer, who was among the first to recommend 
the removal of the appendix during the free interval, comes 
to the following conclusions in his paper already men- 
tioned: "1. In case of diffuse perforative appendicitis the 
operation must always be done at once. 2. In cases of 
acute appendicitis the patient always needs careful obser- 
vation. If the pulse goes above 116 and 120 and has a 
tendency to stay there, the indication for an operation is 
given. In cases of doubt the operation is better than 
waiting. In cases of subacute attacks of appendicitis, also 
after the first severe attack from which the patient recovers 
without immediate operation, the appendix should be re- 
moved. The appendix once inflamed has to be looked upon 
as a diseased organ which is very apt to give repeated and 
more serious, even fatal, trouble in the future." 

Among the German surgeons Sonnenburg, and especially 
Riedel, 1 are advocates of early surgical intervention in the 
grave forms of appendicitis. Riedel says : " As soon as the 
temperature reaches 101°, the pulse 100, the immediate 
removal of the appendix is indicated. ... A tumor which 
lias developed, accompanied by fever and an acceleration 
of the pulse, is always an indication for immediate opera- 
tion." R. Stein 2 and Henry J. Wolf, 3 in papers read quite 
recently before the German Medical Society of New York, 
urged early surgical intervention in all the graver forms 
of appendicitis. 

W T ith Penzoldt, Nothnagel, Ewalcl, Boas, and others I 
would give the following indications for surgical interven- 
tion in this disease : 

Riedel: "Ueber die sog. Friihoperation bei Appendicitis puru 
lenta resp. gangraenosa. " Berliner klinische Wochenschrift, 1899, 
33 und 34. 

2 R. Stein: Deutsche med. Wochenschr., 1899, p. 440. 

3 H. J. Wolf: New Yorker medicinische Monatsschrift, 1899. 



APPENDICITIS. 231 

1. Diffuse peritonitis in consequence of perforation of 
the appendix demands immediate operation. As a rule the 
following symptoms will be found : Sunken and drawn fea- 
tures, cyanosis, a small and very frequent pulse, an increase 
of the painful area, often also a bloated condition of the 
abdomen. 

2. Whenever an appendicular abscess showing fluctua- 
tion is present, an operation should be performed. 

3. If the protracted course of the disease points to the 
existence of an abscess, giving rise to slight septic symp- 
toms, an operation should be undertaken. 

While in these three groups there can be no hesita- 
tion in recommending the operation, in the following 
groups the necessity of surgical intervention must be con- 
sidered and decided in each individual case. 

4. (a) If the rational treatment does not produce any im- 
provement in the course of three to five days, the symptoms 
persisting in undiminished severity or becoming even more 
pronounced, an operation may be resorted to. (b) A sud- 
den rise of temperature lasting over twenty-four hours, 
after the first few days of sickness, is also an indication for 
operation, (c) A very frequent pulse, not corresponding 
to the degree of fever, is another symptom which justifies 
the consideration of an operation, (c/) If the tumor con- 
tinues to increase in size after the fifth day of sickness, an 
operative treatment should be considered. 

5. The removal of the appendix should be undertaken : 
(a) In all cases of appendicitis in which after recovery the 
pain in the right iliac region persists for a long time (sev- 
eral months) ; (b) in recurrent appendicitis if the attacks 
have been quite severe or if they have followed each other 
at short intervals. 



CHAPTER IX. 

INTESTINAL OBSTKUCTION. 

(Acute and Chronic.) 

Introductory Remarks. — By intestinal obstruction is un- 
derstood a great variety of conditions which, although 
unlike in character, have yet the common feature of me- 
chanically causing an obstruction to the passage of con- 
tents along the intestine. Leichtenstern l distinguishes the 
following three groups with regard to the causation of the 
intestinal obstruction : 

1. Occlusion due to pressure from without or com- 
pression of the intestinal lumen in the full sense of the 
word. To this group belong incarcerations of the intes- 
tines in apertures, in slits, and in hernial openings; 
strangulation by pseudo-ligaments, the vermiform proc- 
ess, and diverticula; compression by tumors, by the mes- 
entery, or by displaced abdominal organs. Rotations of 
the intestinal tube around its axis (torsions) and forma- 
tion of knots also belong to this category. 

2. Occlusion from within the intestinal lumen (obtura- 
tion). The obturation may be produced either by gall 
stones, enteroliths, foreign bodies, hardened fecal masses, 
or by neoplasms of considerable size, especially polypi. 
Intussusception (involution of one coil of the bowel into 
another) also belongs to this class. 

leichtenstern: " Verengerungen, Verschliessungen und Lagever- 
anderungen des Darms. " Ziemssen's " Handbuch der speciellen Patho- 
logie und Therapie, " Bd. vii., Leipzig, 1878. 



ACUTE OBSTRUCTION. 233 

3. Occlusions which originate from factors within the 
intestinal wall and causing narrowing of the lumen either 
directly or indirectly. Constriction may occur either in 
circular form (strictures) or as a result of flexions. Ob- 
structions developing after chronic peritonitis, distortions, 
and angular bends of the intestine, cicatricial stenoses 
as well as those produced by neoplasms, belong to this 
class. 

Notwithstanding the diversity and great multiplicity of 
the anatomical factors causing stenoses and obstructions of 
the intestines, the clinical picture and the consecutive le- 
sions which they evoke greatly resemble each other. It 
will therefore perhaps be practical to give first the clinical 
picture of complete obstruction of the bowels (ileus) and 
of stenosis of the intestine, and then to discuss the differ- 
ent anatomical causes and also the differential diagnosis. 

ACUTE INTESTINAL OBSTRUCTION. 

Synonyms. — Ileus, miserere, passio iliaca. 

Definition. — An acute stoppage of the passage of the in- 
testinal contents. This may be caused either by a me- 
chanical occlusion at a certain part of the intestinal canal 
(mechanical ileus) or by an entire absence of motor power 
in a portion of the bowel (dynamic or paralytic ileus) or 
sometimes by both (mechano-dynamic ileus). 

Etiology. — The etiology of ileus is quite complicated, 
and it will be best to analyze separately the different factors 
producing it. 

Compression of the Intestines. Compression of the in- 
testines can occur : (1) by strangulation through adhesions, 
bends or pseudo-ligaments, by Meckel's diverticulum, by 
normal structures abnormally attached, by slits and aper- 



234 DISEASES OP THE INTESTINES. 

tures in the mesentery and omentum, and by incarcerations 
into herniae; (2) by torsions (volvulus); and (3) by tumors 
from without. 

The primary factor in producing isolated adhesions 
(bands or pseudo-ligaments) is a preceding localized peri- 
tonitis. In some cases these bands may have been con- 
genital and due to intra-uterine peritonitis. The band 
may have the form of a firm fibrous cord or it may be very 
slender and may appear as a tough, rigid thread. Occa- 
sionally it may be of comparatively large size. Seldom 
the constricting ligament has the appearance of an actual 
band, having a width of half an inch or more. 

The strangulation of the intestine by an isolated peritoneal 
adhesion takes place in two ways : first, the intestine may 
be strangulated under the band as beneath a shallow and 
narrow arch; secondly, it may become snared and con- 
stricted by a noose or knot formed by the false ligament 
itself. Strangulation from bands occurs when these are com- 
paratively short and tightly stretched over a firm surface. 
The arch beneath which the implicated bowel passes is 
usually large enough to admit one to three fingers. Stran- 
gulation by a noose or knot requires the presence of a long 
false ligament which must lie loose and free in the abdom- 
inal cavity, being attached only at its two ends. The most 
common way in which a coil of intestine becomes snared 
is where a lax band forms a ring or spiral between its fixed 
points. Through this ring a loop of the small intestine 
slips ; the protrusion becoming larger the implicated coil 
cannot free itself from the noose and is strangulated. 

Strangulation by the formation of a knot is described by 
Leichtenstern in the following manner : " There are several 
kinds of this knotting. The most frequent is the follow- 
ing : A long and loose ligament is fastened at one end to 



ACUTE OBSTRUCTION. 235 

a loop of the small intestine, and hangs in the form of a 
simple coil (Fig. 31); if the top of the intestinal loop 
passes directly through the coil a simple knot is formed 
about the piece of the intestine, as is shown in Fig. 32. 
It is evident that the same result can be produced by the 



Fig. 32. 



Fig. 33. 




Fig. 34. Fig. 31. 

Figs. 31-34.— Types of Constricting Peritonitic Bands. (After Leichtenstern and Treves.) 



coil being drawn over the top of and around the intestinal 
loop. Another and rarer form of knot is produced as fol- 
lows: A long and perfectly loose false ligament forms a 
simple coil between its points of attachment. If now one 
leg of the so-called primary noose passes through it we 
have a knot like that shown in Fig. 33, and if now the 



236 DISEASES OF THE INTESTINES. 

intestinal loop passes directly through (Fig. 34), it be- 
comes firmly caught and strangulated. A common char- 
acteristic of all described knots is that when the strangu- 
lated intestine is freed, the ligament can immediately be 
drawn out straight." 

Strangulation by Meckel's Diverticulum. Meckel's diver- 
ticulum is due to the persistence or incomplete oblitera- 
tion of the vitelline duct. Most commonly it exists as a 
blind tube, given off from the ileum. Its length is about 
three inches. As a rule, it is cylindrical in shape, with a 
conical extremity. Occasionally it presents a globular 
shape and is then called "clubbed." Meckel's diverticle 
is always single and is attached to the ileum one to three 
feet above the ileo-csecal valve. As a rule, the end of the 
diverticulum is free. In some instances it is attached to 
the umbilicus or to the abdominal wall. Sometimes the 
end attached to the abdominal parietes may give way and 
form fresh adhesions with some points of the peritoneal 
surface. The latter occurrence is of great importance with 
reference to strangulation of the intestine, which frequently 
takes place under these conditions. By means of the new 
adhesion of the diverticulum a loop is formed in which 
some portion of the intestine is liable to engage. Another 
possibility for strangulation by the diverticulum is afforded' 
when its end is free and club-shaped. The diverticulum 
forms a ring into which its own free end projects. A loop 
of the intestine entering the centre of this ring may push 
the clubbed end of the process before it and so tie the 
knot, thus leading to obstruction. Again the diverticulum 
may surround the pedicle of an intestinal loop in such a 
way as to encircle it with a single knot (see Figs. 35, 36, 37). 

In a similar manner as Meckel's diverticulum some nor- 
mal structures may act when they are abnormally attached. 



ACUTE OBSTRUCTION. 



237 





Thus the vermiform appendix may become adherent to 
some point of the neighboring peritoneum and so form an 
arch under which 

a loop of the in- FlG ' *■ FlG - * 

testine may b e 
strangulated. 
The Fallopian 
tube may likewise 
become adherent 
to the adjacent 
peritoneum situ- 
ated in the iliac 
fossa and thus 
form an arch in- 
to which a por- 
tion of the intes- 
tine may slip and 
become incarcer- 
ated. Other in- 
ternal organs ab- 
normally at- 
tached may form 
similar traps for 
intestinal stran- 
gulation. 

Of great clini- 
cal importance is 
the strangulation 

of the intestine in slits and apertures of the mesentery or 
omentam. These may be either congenital or of traumatic 
origin. Similar to the action of slits in the production 
of strangulation are also the various internal herniae (her- 
nia duodeno-jejunaliSj hernia retroperitonealis anterior. 




Fig. 37. 

Figs. 35-37.— Knotting of a Meckel's Diverticulum which 
has a Button-like Swelling of its Extremity. (Treves.) 



238 DISEASES OF THE INTESTINES. 

hernia intrasigmoida, hernia bursas omentalis, formed 
by the foramen of Winslow, diaphragmatic hernia). 

In all these cases the mechanism of the obstruction is as 
follows : A coil of gut may be driven with sudden severe 
force beneath the band or through an aperture and become 
practically strangulated at once, as is often the case in 
strangulated hernia. There being no natural force to drive 
the coil out of its place of imprisonment, it remains firmly 
gripped. In other cases the involved intestine may not be 
strangulated at first, but the band pressing upon the mes- 
enteric vessels produces a congestion in the implicated 
coils, which become engorged and distended by an in- 
creased accumulation of gas, and thus complete strangu- 
lation is the result. In other cases, again, the final cause 
of a strangulation is a twisting of the bowel. All the va- 
rieties of intestinal strangulation just mentioned occur in 
the small intestine, the lower portion of the ileum being 
principally affected, less frequently its upper portion or 
the jejunum. 

The occlusion may in some cases be due to kinking of 
the intestine through a band attached to the bowel and 
dragging upon it. Adhesions may also obstruct the bowel, 
compressing its lumen. This occurs when false mem- 
branes are situated around the bowel and have undergone 
shrinking. They then compress the intestine seriously 
and narrow its lumen. The same process of shrinking 
may also effect an obstruction of the bowel if it takes 
place in the mesentery after inflammation. 

Volvulus. By the term volvulus is understood an obstruc- 
tion of the bowel by a twist about its mesentery, or its own 
axis, or the intertwining of an intestinal coil within another. 
Twisting of the bowel occurs most often in the sigmoid 
flexure. The usual cause of this trouble is chronic consti- 



ACUTE OBSTRUCTION. 239 

pation, for in this condition the flexure fs more or less 
constantly distended. Its walls become partly paralyzed 
and hang down into the pelvis, like an inert heavy mass, 
being filled with fecal matter. Traction is thereby exerted 
upon the mesocolon and a loop is soon formed. A twist- 
ing of the latter is brought about either by some displace- 
ment of the bowel or by a sudden change in the position 
of the body. The ascending colon, caecum, and the small 
intestine may also be affected in the same manner, al- 
though less frequently. Intertwining of the intestine is 
here more often met with. 

Obturations of the Intestine. Intestinal occlusion often 
takes place in consequence of obturation of the lumen of 
the gut through foreign bodies lodging therein. Accumu- 
lations of fecal matter may give rise to such an occurrence. 
The hard fecal tumor is then situated either in the caecum 
or in the colic or sigmoid flexures. In these cases chronic 
constipation has existed for a long time. 

Gall stones, although rarely, give rise to intestinal oc- 
clusion. In order to do this they must be of considerable 
size. " The puzzle as to how the camel could go through 
the eye of the needle, i.e., how these enormous gall stones 
could reach the bowel, has been solved, by the assumption 
on fair evidence that an ulcerative process opens the way 
from the gall bladder to the bowel, though doubtless very 
large stones occasionally find their passage through the 
ducts" (E. D. Ferguson 1 ). 

In a similar manner enteroliths may also cause obstruc- 
tion of the bowel. This happens especially if an entero- 
lith situated in an intestinal diverticulum has been dis- 
lodged and found its way into the canal of the gut. 

1 E. D. Ferguson : Transactions of the New York State Medical 
Association, 1898, p. 233. 



240 DISEASES OF THE INTESTINES. 

Foreign bodies which have been accidentally or inten- 
tionally swallowed may under favorable conditions reach 
some part of the bowel and here obstruct the lumen. This 
will occur if the foreign body is of considerable size, or if 
it is not smooth but provided with sharp points. The 
latter catch in a fold of mucous membrane and prevent its 
further passage. The most varied substances have thus 
been found to be the cause of intestinal obstruction : mar- 
bles, stones, coins, glass stoppers, corks, spooDS, knives, 
forks, keys, needles, pins, buttons, false teeth with the 
plate. Kernels of fruit like cherries, prunes, etc., may 
accumulate in the bowel and by means of fecal matter be 
kept together, forming a large conglomeration, completely 
obstructing the canal. 

Eecently Murphy's button has also been found in a few 
instances to cause obstruction of the bowel. 

Intestinal parasites (tapeworms, ascaris lumbricoides) , if 
present in large numbers, may also form a mass obstruct- 
ing the canal. This occurs especially after a vermifuge 
has been administered and the dead parasites have re- 
mained within the canal. 

Similar to the action of foreign bodies are also tumors 
(polypi, fibroma, myoma, etc.) 'connected by a pedicle 
with the intestinal wall, filling up its lumen. 

Intussusception. Intussusception or invagination means 
the prolapse of one part of the intestine into the lumen of 
an immediately adjoining part. An intussusception shows 
in a vertical section six layers of intestine, three on either 
side of the central canal, which are more or less parallel to 
one another. The arrangement of the layers is such that 
mucous membrane is in contact with mucous membrane, and 
peritoneum with peritoneum. On transverse section the 
invaginated mass shows three concentric rings of bowel. 



ACUTE OBSTRUCTION. 241 

The external of the three layers is called the intussusci- 
piens, the sheath, or the receiving layer. The innermost 
cylinder is called the entering layer and the middle one the 
returning layer. The latter two together form the intus- 
susceptum. The neck of the intussusceptum is at its up- 
per part where the returning layer joins the sheath. 

In case the intussusception lasts for some time the se- 
rous surfaces of the gut touching each other may become 
glued together and ultimately adherent. This will prevent 
the disengagement of the invaginated portion, while its fur- 
ther passage into the other bowel will not be interfered 
with. The mesentery always participates in the invagina- 
tion and becomes more or less compressed and wedged in 
by the sheath. The whole mass of a simple intussuscep- 
tion may in its turn become invaginated and give five in- 
stead of three coats, or even seven if the process is re- 
peated, so that the upper edge of the intussuscipiens is 
rolled over like a cuff. These double and triple intussus- 
ceptions are comparatively rare. 

With regard to the mechanism of intussusception Noth- 
nagel's experiments on animals have proven of greatest 
value. According to this writer intussusception may be 
due either to a localized spastic contraction of a portion 
of the bowel or to a total paralysis. The normal gut im- 
mediately below the contracted part slips upward to a slight 
extent over this strongly contracted and greatly narrowed 
portion, and invagination is thus produced. Again if a 
segment of the bowel is paralyzed, the gut lying immedi- 
ately below it, on contraction will slip into the paralyzed 
portion and thus an invagination may arise. 

Intussusception may take place at any point within the 

entire small and large intestines. Over fifty per cent of 

the cases consist of the invagination of the ileum into the 
16 



242 DISEASES OF THE INTESTINES. 

colon. With regard to the remote cause of intussuscep- 
tion Treves 1 has examined a number of reported cases and 
found it in one hundred examples of intussusception dis- 
tributed as follows : 

1. No evident exciting cause 62 per cent. 

2. Diarrhoea, dysentery, enteritis, marked irregularity of 

the bowels 8 " 

3. Polypi 5 " 

4. Ingesta 5 " 

5. Injuries and exposure to cold 5 " 

6. Certain acute and chronic ailments which may or may 

not have had a concern in the etiology, such as 
typhoid fever, whooping-cough, measles, scarlet 
fever, smallpox, cholera, and hernia ; with these 
may be included pregnancy and labor 15 " 

Total 100 " 

This clinical form of intussusception must not be con- 
founded with agonal intussusception, which, as the term 
indicates, occurs shortly before death and is purely of 
anatomical importance. The agonal form of intussuscep- 
tion is sometimes found multiple and is met with fre- 
quently at autopsies of children who have died from affec- 
tions of the brain. 

Pathological Changes. — The lesions which are encountered 
in acute ileus, no matter what be its origin, are the follow- 
ing: The intestinal coils above the occluded part of the 
bowels present a quite different appearance from those 
below. The former are distended, filled with gas and ill- 
smelling feculent contents; and this ectatic condition is 
the more pronounced the nearer they are situated to the 
occluded part. If the occlusion lies in the jejunum or 
ileum, the distention will involve the entire upper portion 
of the small intestine and also the stomach. If, however, 
the stoppage is situated within the colon, the dilatation 
1 Treves: "Intestinal Obstruction," p. 211. 



ACUTE OBSTRUCTION. 243 

will at first occupy that portion of the colon situated be- 
tween the ileocecal valve and the obtruded spot, while 
the small intestine may remain unchanged, the ileocecal 
valve acting in its usual way and thus preventing an over- 
flow of the contents of the colon into the small intestine. 
Under such circumstances the dilated portion of the colon 
may attain considerable size, resembling almost the stom- 
ach. After the condition has lasted a few days, however, 
the ileocecal valve ceases to functionate and now the con- 
tents of the colon overflow the small intestine and the 
stomach and these organs become also overfilled and dis- 
tended. The portion of the intestine situated below the 
occlusion is empty and contracted. 

The intestinal coils above the occluded spot are usually 
engaged in very active peristaltic movements, which repre- 
sent an attempt of nature to overcome the obstacle. After 
these peristaltic motions have lasted a few days, a paralytic 
state of the intestines supervenes. 

The intestinal mucosa situated near the occlusion is 
subjected to great mechanical and chemical irritations 
due to the constant presence of considerable amounts of 
decomposed material, and thus grows intensely inflamed. 
Often ulcers develop which may penetrate the wall of 
the bowel and cause fatal peritonitis. In rare instances 
after such a perforation, adhesion to neighboring intes- 
tinal coils may occur and give rise to fecal abscesses 
and abnormal communications between different intestinal 
segments. By means of a similar process an opening may 
be established between the intestine and the abdominal 
walls in such a manner that the fecal matter finds an exit 
here (anus praeternaturalis). 

Localized or general peritonitis is thus often present in 
cases of intestinal obstruction. Serous, bloody, or puru- 



244 DISEASES OF THE INTESTINES. 

lent exudation is frequently found in the abdominal cav- 
ity. The anatomical lesions are most pronounced in the 
immediate vicinity of the occluded intestine. This is due 
not only to the stoppage of the intestinal contents but also 
to interference with the circulation of the gut produced by 
the same factors which have caused the obstruction. Nu- 
merous large and small mesenteric veins become com- 
pressed, thus causing congestion and hemorrhages. The 
intestinal walls appear infiltrated with blood, showing ec- 
chymoses at various places, and may even appear dark 
red. In the neighborhood of the occlusion the intestine 
may be covered with black curdled blood in the form of 
a membrane. Its walls become brittle and gangrenous. 

Symptomatology. — The symptoms of acute intestinal ob- 
struction appear either suddenly or after slight disturb- 
ances have existed for a few days, as for instance diar- 
rhoea, constipation, feeling of uneasiness. In some 
instances the history of an exciting cause is given. Thus 
a severe blow on the abdomen, violent bodily exertion, a 
cold, a too copious meal, or a strong laxative. 

The patients are first seized with violent abdominal 
pains, sometimes of a crampy character. The pain may 
be felt at first at a certain definite spot within the abdo- 
men, while later it becomes more diffuse. In other in- 
stances the patient is unable to localize the pains dis- 
tinctly. Occasionally the area around the navel is given 
as the seat of the pains, while in other cases they are re- 
ferred to the entire abdomen. The pain usually exists un- 
interruptedly, though it may show exacerbations from time 
to time. Soon after the occurrence of these colicky pains 
eructations of gas and then vomiting appear. At the be- 
ginning gastric contents are ejected, later bile, and finally 
offensive feculent material is brought up. The latter usu- 



ACUTE OBSTRUCTION. 245 

ally has a yellowish-brown color, is liquid, and contains 
only very fine, small, solid particles suspended in the fluid. 
At this period the eructated gases have a fetid odor and 
hiccough almost constantly distresses the patient. After 
the act of vomiting the patient may feel somewhat relieved 
for a short while, but soon there is a return of the severe 
symptoms. 

Almost simultaneously with vomiting, meteorism of the 
abdomen ensues. The passage from the rectum is entirely 
stopped and there is no evacuation either of fecal matter 
or of flatus. The meteorism may involve either a certain 
region of the abdomen or the entire cavity. The tympani- 
tes gradually increases and a feeling of tension becomes 
more and more pronounced. The diaphragm is soon 
pushed upward by intestinal coils filled with gas in such 
a manner that the liver dulness may be absent from the 
entire right thoracic cavity. Dyspnoea supervenes; the 
breathing becomes accelerated and superficial, assuming 
the thoracic type. The pulse is small and frequent. The 
extremities are cold, the skin is covered with perspiration, 
the face is pale, bearing the expression of utmost anguish, 
the eyes are sunken, dryness of the throat and extreme 
thirst exist, and the patient is barely able to use his voice. 
These extremely painful and tormenting symptoms persist 
and the patient succumbs — unless there is a change in the 
course of the disease — remaining conscious until the end. 

After having given a general description of the clinical 
picture of ileus it will not be amiss to discuss each symp- 
tom separately. 

1. Pains. Pain, the most constant and conspicuous 
symptom of intestinal obstruction, depends upon several 
conditions. It is usually due, first, to the injury inflicted 
on the peritoneum and the intestinal walls in consequence 



246 DISEASES OF THE INTESTINES. 

of the strangulation; secondly, especially at a somewhat 
later period, to the tumultuous and increased irregular 
peristaltic movement of the intestines. These movements 
above the site of obstruction are of a very intense charac- 
ter and produce " colic " as well as exacerbations of the 
pains which occur at certain intervals. The intensity of 
the pain depends upon the degree of excitability of the 
individual, upon the state of the sensorium, upon the ex- 
tent of the intestine and peritoneum involved, and upon 
the severity of the occluding lesion and the rapidity of its 
occurrence. Later on the pain is influenced by the dis- 
tention of the gut and by the presence or absence of peri- 
tonitis. 

At the commencement of the disease the pain is fre- 
quently not aggravated and sometimes relieved by press- 
ure. Later, however, the pain is considerably increased 
by even slight pressure, the cause of this being the pres- 
ence of peritonitis. 

According to Treves, 1 the pain is constant, although 
liable to periodical exacerbations in cases of complete ob- 
struction. In cases in which the obstruction is but par- 
tial the pain is distinctly intermittent, and the patient 
experiences intervals between attacks of pains during which 
he is free from suffering. The pain as a rule grows more 
intense with the progress of the disease. There may be, 
however, a diminution in the severity of the pain for a short 
period before a fatal issue, caused by a collapse, paralysis 
of the intestine, rupture or perforation of the bowel, or by 
a diminished activity of the sensorium. 

Treves has pointed out that no matter in what part of the 
small intestine the obstruction is situated, the pain arising 
therefrom is usually referred to the region of the umbilicus. 
*F. Treves: "Intestinal Obstruction," Philadelphia, 1884. 



ACUTE OBSTRUCTION. 247 

If the obstruction is localized in the large bowel, then the 
pain may be experienced, especially at the beginning of 
the disease, at the seat of the lesion; later, however, the 
pain may assume a more diffused character or may be felt 
at other regions of the abdomen. This is the reason why 
only the initial pain is of some diagnostic significance with 
regard to the seat of the lesion. 

2. Vomiting. Vomiting is almost always present. At 
the beginning of the disease it is of reflex origin due to 
the irritation of the peritoneum ; later on it must be as- 
cribed principally to the irregular, strong, peristaltic con- 
tractions of the intestines. The appearance of fecal vom- 
iting was believed by the old writers to be a sign that the 
obstruction was situated in the large bowel. Nowadays, 
however, it is generally known that this symptom is often 
present in cases in which the obstruction is situated in the 
ileum or even in the jejunum. The reason of absence of 
putrefactive processes in the intestinal contents normally is 
the rapidity with which they are moved farther on along 
the canal until they reach the large bowel. In obstruction, 
however, the peristaltic contractions are much slower and 
thus putrefactive processes develop even in the small bowel. 

In order to explain the mechanism of stercoraceous vom- 
iting a reversed peristaltic or antiperistaltic motion of the 
intestines was formerly assumed. Of late, however, the 
mechanism of fecal vomiting as expounded by Haguenot ' 
as early as 1713, is now generally accepted. According to 
this author, stercoraceous vomiting takes place in the fol- 
lowing manner : Above the occluded intestine there is an 
accumulation of more or less liquid intestinal contents in 

1 Haguenot: "Memoire sur les Mouvements des Intestins dans la 
Passion Iliaque. " Histoire de 1'Academie Royale des Sciences, Paris, 
1713. 



248 DISEASES OF THE INTESTINES. 

considerable quantity; the bowels being distended with 
large amounts of gas are under constant pressure, which 
is increased after each inspiration and especially after 
energetic contraction of the abdominal muscles, occur- 
ring for instance during the act of vomiting. Under the 
influence of pressure the stagnant liquid contents are re- 
gurgitated from above the occluded spot into places in 
which there is less resistance and thus reach the duo- 
denum and the stomach. Here they irritate the mucous 
membrane and cause vomiting. 

This theory is perfectly in accord with the circumstance 
that in stercoraceous vomiting mostly liquid or sometimes 
semi-liquid contents are evacuated, but never solid fecal 
matter; for even in obstruction of the colon the fluid will be 
moved farther upward while solid particles will remain in 
the lower portion of the bowel. Vomiting of formed fecal 
matter is a very rare occurrence, and must be ascribed to an 
existing fistulous opening between the colon and stomach. 

3. Constipation. Constipation almost always exists and 
is very obstinate. After injections, very rarely spontane- 
ously, there may be a slight movement of the bowel con- 
sisting of the fecal matter lodged below the occluded spot. 
In some rare instances a catarrhal condition may exist 
in the segment of the bowel below the obstruction, and 
the patient then may rather have diarrhoea combined with 
tenesmus. Of greater significance than the absence of 
stools is the inability to pass wind through the anus. The 
passage of flatus is a sure sign that the permeability of the 
intestine has been re-established. 

4. Meteorism. Meteorism is the result of increased for- 
mation of gas developing in consequence of putrefactive 
processes as well as of diminished absorption. According 
to Zuntz, the absorption of intestinal gases into the blood 



ACUTE OBSTRUCTION. 249 

takes place only when the circulation is in good working 
order. Meteorism thus indirectly points to a disturbed 
circulation which is often found in cases of incarcerations. 
If meteorism is absent the absorption of gases must be 
assumed to take place as rapidly as their formation. Me- 
teorism may be at first present at a certain circumscribed 
spot of the abdomen and later become more diffuse. If 
the place at which it first appears can be distinctly defined, 
this is of diagnostic importance with regard to the location 
of the occlusion. 

If the occlusion is in the large bowel the portion situated 
between it and the ileocecal valve will become considera- 
bly distended with gas. Thus a protrusion of the right 
side of the abdomen will be noticed when the obstruction 
is at the right flexure. If the obstacle is situated in the 
rectum there is at first a protrusion of the left side of the 
abdomen and later the tympanites will involve the portion 
of the abdomen situated above the navel (course of the 
transverse colon) . In some instances, however, obstruction 
of the rectum may be acompanied by more or less general 
meteorism. This is especially the case after the disease 
has lasted some time ; for then, as a rule, the resistance of 
the ileocecal valve is overcome by the gas pressure and 
it remains more or less patent in such a way that the gases 
easily penetrate the small intestine. 

In occlusions affecting the duodenum or the upper part 
of the jejunum the meteorism as a rule involves the upper 
half of the abdomen, and remains confined to this area. 
After vomiting there is usually a perceptible decrease of 
the protrusion for a short while. 

If the meteorism has lasted for some time and is in- 
tense, the abdomen assumes a barrel shape. This is espe- 
cially found in cases in which the distended intestinal coils 



250 DISEASES OF THE INTESTINES. 

are already paralyzed. The accumulation of gas can now 
go on without encountering much resistance and thus do 
great harm. The diaphragm is then pushed upward. The 
lungs as well as the heart become compressed. Stomach, 
liver, and bladder are compressed by the intestinal coils 
filled with gas lying upon them. In a similar manner the 
large veins (vena cava, vena portse, etc.) are subjected to 
the same disturbance. Thus the function of many impor- 
tant vital organs is interfered with and impaired to such a de- 
gree, if this condition persists, that a fatal issue may occur. 

5. Collapse. The diverse symptoms of shock which ap- 
pear in a marked degree in cases of ileus must be ascribed 
to the sudden damage inflicted upon the peritoneum and 
intestinal wall by the strangulating agent. The mechani- 
cal irritation involves first the splanchnic nerves, and 
through them the circulatory apparatus. As a conse- 
quence there are a lowering of the temperature of the sur- 
face, cold sweats, lividity of the extremities, anaemia of the 
brain, and a small and rapid pulse. The degree of the 
collapse depends upon the disposition of the patient, upon 
the suddenness of the strangulation, and upon the amount 
of peritoneum or of intestine involved in the lesion. 

The gravest amount of shock is met with in cases in which 
a considerable segment of the intestine is suddenly strangu- 
lated and an injury thus abruptly inflicted upon an exten- 
sive nerve area. As a rule, the shock met with in cases of 
obstruction of the small intestine is much more pronounced 
than in cases in which the obstruction is situated in the 
large bowel. The reason for this is the greater supply of 
nerves and the greater activity of the small intestine as 
compared with the large bowel. The nerves of the small 
intestine are also more directly associated with the great 
sympathetic ganglia of the abdomen. 



ACUTE OBSTRUCTION. 2.31 

6. The Decrease of the Amount of Fluid in the Blood. 
In intimate connection with the disturbance of the nerves 
and circulatory functions just described is the decrease in 
the amount of fluid in the blood. This is due to increased 
secretion in the intestine with absence of absorption, to 
vomiting, and to increased perspiration. As a consequence 
there exist dryness of the tongue and a tormenting thirst; 
the urine is also passed only in small quantities, and in 
some instances there may even be anuria. 

Certain symptoms which occur bat rarely and also be- 
long more or less to this group are cramps, tetanus, coma, 
delirium, fever. Whether these symptoms are due to 
auto-intoxication or to other factors (especially the dry con- 
dition of the blood) is as yet not settled. 

Objective Signs. — Inspection reveals either a symmetri- 
cal fulness of the abdomen (sometimes barrel shaped) or a 
protrusion of certain parts. Thus, as mentioned above, 
the upper part of the abdomen is protruded when the oc- 
clusion involves the duodenum or the upper part of the 
jejunum. The right iliac region is intensely tympanitic 
if the occlusion involves the hepatic flexure, while the left 
iliac region is the seat of the protrusion if the occlusion 
involves some portion of the descending colon. After the 
disease has existed for some days there is as a rule a gen- 
eral marked swelling of the abdomen. 

Palpation reveals in some cases a circumscribed area 
which is painful on pressure and thus serves to localize 
the seat of the disease. This is especially the case very 
soon after the onset of the symptoms. In the larger num- 
ber of cases, however, there is a special tenderness either 
in the region of the navel alone or over the entire abdomen. 
In comparatively few cases will palpation reveal a tumor 
situated deeply within the abdomen and in direct connec- 



252 DISEASES OF THE INTESTINES. 

tion with the site of obstruction. This occurs especially 
in intussusception, strangulation, in occlusions due to com- 
pression by tumors, and in fecal impaction. After a thor- 
ough palpation of the abdomen a digital examination of 
the rectum and also of the vagina should be performed. 
It is hardly necessary to add that a thorough examination 
should be made of any existing hernia which may be the 
seat of incarceration. 

By means of auscultation either from a distance or in 
the immediate neighborhood of the abdomen we are often 
enabled to judge about the state of the intestinal peristal- 
sis; for when the latter takes place in a violent manner 
splashing and gurgling noises are always audible. 

Percussion is usually of great importance. In general 
meteorism it permits us to judge of the position of the dia- 
phragm and liver. If percussion shows a change in char- 
acter over a certain region of the abdomen during a period 
of a few minutes, it follows that the condition of an intes- 
tinal coil lying beneath has undergone some change in its 
state of fulness, and thus indicates that the bowel is still 
in active peristalsis. Auscultation and percussion may be 
used conjointly and serve the same purpose. In case no 
change whatever is noted on percussion for a very long 
period of time, there is a suspicion that paralysis of the 
bowels exists. The liver dulness will be found either 
partly or entirely absent in almost all cases of perforation, 
but in some rare instances even without perforation. In 
the latter event we must assume that intestinal coils filled 
with gas are lying above the liver. I have observed such 
a case with recovery during the last year. Sometimes per- 
cussion may help to discover existing exudation, dulness 
being found in the lower part of the abdomen. 

Examination of the vomited matter will show the pres- 



ACUTE OBSTRUCTION. 253 

ence or absence of fecal elements. The urine is scanty, 
very concentrated, often contains albumin, and almost al- 
ways shows an increase of indican and phenol. Rosen- 
bach's reaction is almost always present. 

Course. — The course of an acute obstruction will depend 
first upon its location, and secondly upon its nature. The 
higher up in the intestine the obstruction is situated the 
more rapid as a rule is the course of the disease. Volvu- 
lus and strangulation of the intestine are generally accom- 
panied by a more violent course than is obturation by for- 
eign bodies. The duration of the disease is not always 
the same. In some instances the patient dies very soon, 
a few hours or a clay or two after the commencement of 
the obstruction, of shock and paralysis of the heart. In 
other instances the disease lasts several days or even a 
week. In intussusception the duration of the disease is 
longer, several weeks, showing periods of exacerbations 
and remissions. 

If the patient recovers from the collapse and there 
is a spontaneous re-establishment of the patency of the in- 
testinal lumen (i.e., the obstruction is relieved, which may 
happen in cases of invagination, torsion, and obturation 
by foreign bodies), there is at first as a rule a passage 
of flatus, which may be followed by a fecal movement of 
offensive odor. In case of invagination there is often some 
blood in the evacuation. All the symptoms which have 
previously existed begin to abate, the fecal vomiting ceases, 
the meteorism becomes less, and the patient gradually re- 
covers from his severe illness. In cases in which the intes- 
tinal obstruction has led to considerable anatomical changes 
within the lumen of the bowel (ulcers, gangrenous proc- 
esses, adhesions), after a period of comparative euphoria,, 
symptoms of chronic intestinal obstruction may develop. 



254 DISEASES OF THE INTESTINES 

In the greater number of cases of acute intestinal ob- 
struction the latter persists, and the patient, if not oper- 
ated upon, generally dies of diffuse peritonitis, with or 
without perforation of the intestine. Even without per- 
foration, peritonitis may readily develop in consequence of 
the paralytic state of the intestine; for, according to Bon- 
necken, J bacteria can easily penetrate the intestinal wall as 
soon as the latter is in a paralyzed condition and thus give 
rise to inflammation of the peritoneum. 

Circumscribed peritonitis around the occluded part need 
not give distinct symptoms. General peritonitis, however, 
always enhances the alarming symptoms already existing. 
Thus the meteorism increases; the dyspnoea, hiccough, 
and vomiting become more violeut, the pains unendur- 
able ; the heart begins to give out and pronounced collapse 
appears. Generally there is a rise of temperature and 
frequently a fluid exudation within the abdomen is dis- 
coverable. If perforation of the intestine has taken place, 
the symptoms just described appear still earlier and with 
more violence. The abdomen becomes more or less 
rounded and the diaphragm is pushed upward in the high- 
est degree. The liver dulness disappears and the pains be- 
come excruciating. The shock may be so great that the 
patient becomes unconscious and remains so until death 
brings relief. 

Complications appearing during the disease may also be 
the cause of death. Thus deglutition pneumonia (Schluck- 
pneumonie) which occasionally occurs by aspiration into 
the lungs of gastric and intestinal contents during the act 
of vomiting, or septicaemia in consequence of intestinal per- 
foration, may develop with embolic processes in the lungs, 
liver, and other organs. In exceptional cases there occurs 
1 Bonnecken : Virchow's Archiv, Bd. 120. 



ACUTE OBSTRUCTION. 255 

an adhesion of the occluded intestinal coils to the anterior 
abdominal wall, and after the gangrenous destruction of 
the latter as well as of parts of the gut, an anus praeter- 
naturalis develops, or a fistulous opening between two por- 
tions of the intestines, or again a fistula of the intestine 
into the bladder, uterus, vagina, or stomach. 

Diagnosis. — The diagnosis must deal with the following 
three points : A. Recognition of the intestinal obstruction. 
B. Its seat. C. Its etiological factor. 

A. Recognition of the Intestinal Obstruction. The recog- 
nition of an acute intestinal obstruction is not difficult if 
the symptoms described above are present in a marked 
degree. Thus total absence of passage of fecal matter and 
flatus combined with symptoms of collapse, meteorism, 
pains, and fecal vomiting will permit a positive diagnosis 
of intestinal obstruction. In many instances, however, only 
a few of the symptoms mentioned are present, and then 
the diagnosis is quite difficult. The symptom of the great- 
est diagnostic value is fecal vomiting, although even this 
alone does not always warrant the diagnosis of obstruction, 
for it also occurs in intestinal paralysis. The latter con- 
dition must be especially borne in mind in cases in which 
there has been a history either of contusion of the ab- 
domen or of a reposition of incarcerated hernia shortly 
before the appearance of the disease. The fecal vomiting 
of hysterics can also be easily recognized, as there are 
always symptoms present which indicate the true condi- 
tion. 

The greatest difficulty in diagnosis lies in the differenti- 
ation between intestinal obstruction and diffuse peritonitis, 
especially if the latter accompanies appendicitis. All the 
symptoms characteristic of intestinal obstruction may oc- 
cur also in peritonitis. A thorough consideration of all 



256 DISEASES OF THE INTESTINES. 

the symptoms and their differentiation in these two dis- 
eases will, however, permit a decision. 

The following points will serve as a guide in this connec- 
tion : In acute peritonitis there is a rise of temperature at 
the beginning of the disease, while in intestinal obstruction 
there is at first no fever or even a subnormal temperature. 
There are exceptions, however, and a general peritonitis of 
a grave nature may run its course without any fever but 
with symptoms of collapse. The pains on pressure over the 
abdomen are much more intense in peritonitis ; in intesti- 
nal occlusion the spontaneous pain may occasionally even 
be relieved by pressure. Fecal vomiting is of compara- 
tively rare occurrence in peritonitis, and if present it usu- 
ally appears later than in intestinal obstruction. The me- 
teorism is diffuse in peritonitis right from the start. It 
thus causes a general distention of the abdominal parietes. 
In obstruction the accumulation of gas is at first less pro- 
nounced, circumscribed, and increases gradually. In peri- 
tonitis the abdomen becomes tense from the first, while in 
obstruction, at the commencement at least, it is as a rule 
soft. The existence of an exudation speaks in favor of 
general peritonitis. In peritonitis accompanying appen- 
dicitis there will be besides the above symptoms the phe- 
nomena characteristic of the latter disease. In some in- 
stances, however, the differentiation between peritonitis 
and obstruction will hardly be possible and mistakes are 
liable to occur. 

Acute intestinal obstruction is occasionally simulated by 
poisoning with arsenic and also by a very severe attack of 
cholera. In the former condition there will be a history 
of poisoning, and in the latter the presence of cholera ba- 
cilli in the dejecta will clear up the diagnosis. In rare 
instances a severe attack of biliary colic or of renal colic 



ACUTE OBSTRUCTION. 257 

may in some respects resemble intestinal obstruction. A 
thorough examination, however, will always reveal the true 
condition. In biliary colic as a rule there is swelling of 
the liver and sometimes jaundice; in renal colic the pains 
radiate from the kidney to the bladder, there is a burning 
sensation during urination, and the urine often contains 
mucus and occasionally a few pus corpuscles or blood cells. 
Intestinal colic resulting from chronic lead poisoning occa- 
sionally simulates true obstruction of the bowels. The 
anamnesis, however, will show that we have to deal with 
lead poisoning. Besides, in these cases there is, as a rule, 
a more or less sunken condition of the abdomen. Simple 
intestinal colic (of nervous origin) will hardly ever give rise 
to mistakes in the diagnosis, as the clinical picture is less 
severe and the disease quickly subsides, 

B. Location of {he Obstruction. The location of the seat 
of the obstruction is not merely of theoretical value, but of 
great practical importance, for this decides the question 
as to where abdominal incision should be made in cases of 
operation. It will be useful to discuss first at what point 
of the abdomen the obstruction is situated, and secondly, 
what particular portion of the bowel it involves. 

1. The point at which the patient first experiences pain 
is significant in case he is able to locate it definitely. In 
many instances, however, the pain is not experienced in 
one circumscribed spot, and is often located diffusely in 
the neighborhood of the navel. The presence of a tensely 
tympanitic intestinal coil, which does not change its con- 
figuration and thus makes the abdominal wall protrude 
asymmetrically, is of great importance; for, according to 
Von Wahl, such a coil is often found above the occluded 
segment of intestine. Strong peristaltic contractions run- 
ning in the same direction over a certain region of the ab- 
17 



258 DISEASES OF THE INTESTINES. 

domen, especially if they return periodically and always 
in the same area, will serve to locate the place at which 
the obstruction is situated. For these peristaltic waves 
pass along the intestine down to the seat of the obstruc- 
tion, which they are unable to overcome. 

Palpation of the abdomen occasionally reveals the pres- 
ence of a sausage-like tumor. This occurs especially in 
cases of intussusception. If such a tumor is present, the 
location of the obstruction is certainly easy. A thorough 
examination of all hernial openings will occasionally re- 
veal an incarceration of the intestine and also show the 
site of the lesion. If there is no hernia the examination 
must be continued through the vagina and through the rec- 
tum. The exploration through the vagina will show whether 
the pelvic organs are normal, and if not, whether a tumor 
originating from the genital organs is compressing the in- 
testines. Digital examination of the rectum will enable us 
to discover a stricture, an intussusception, or a tumor of 
the lower portion of the bowel. In some cases a thorough 
examination of the entire rectum and the descending colon 
may be undertaken with the whole hand under chloroform 
narcosis, according to the method of Simon. In cases of 
intussusception involving the sigmoid flexure and rectum, 
the anus often remains open (paralysis of the sphincters) 
and there appears an involuntary evacuation of a muco- 
bloody fluid from time to time. 

2. Determination of the Portion of the Intestinal Tract in 
ivhich the Obstruction is Situated. Small Intestine. If the 
obstruction is situated in the small intestine all the symp- 
toms (pains, vomiting, collapse) are, as a rule, much more 
intense and appear sooner than in obstruction of the large 
bowel. Soon after the commencement of the disease, there 
is copious vomiting which may become fecal after a short 



ACUTE OBSTRUCTION. 259 

period. The meteorism at the beginning is localized in the 
upper part of the abdomen, while the lower part remains 
unchanged. Pronounced visible peristaltic waves in the 
small intestine also point to an occlusion situated within 
the latter. 

Jaffe ' was the first to show that obstruction of the small 
intestine gives rise to pronounced indicanuria. As early 
as the second or third day of the obstruction, indican can 
be found in the urine in large quantities. In obstruction 
of the large bowel there is as a rule no indicanuria, and if 
it appears it does so only later in the disease, on the sixth 
or seventh day. The higher up in the intestinal tract the 
obstruction is situated, the sooner and the more frequently 
anuria may appear. Injections of water into the bowel 
may secure a fecal evacuation. The colon can also be 
filled with a large amount of water or gas. 

If the obstruction is situated within the duodenum or in 
the upper part of the jejunum, it can often be easily recog- 
nized. Obstruction of the duodenum above Vater's papilla 
will manifest the same symptoms as acute dilatation of the 
stomach in consequence of a stricture. There will be ischo- 
chymia and continuous vomiting of chyme. An obstruc- 
tion situated within the duodenum below Yater's papilla 
will give rise to vomiting of large quantities of pure bile. 
The vomited matter may contain acids from admixture of 
gastric juice. It is never fecal in character. The gastric 
region is protuberant but sinks in after a spell of vomiting. 

If the obstruction is situated within the beginning of the 
jejunum the vomiting assumes at first a greenish hue (de- 
composed bile) which may be followed by the vomiting of 
pure unchanged yellow bile. Occasionally the vomited 
matter assumes a fecal character. Obstructions situated 
1 Jaffe : Centralbl. f. die med. Wissenscbaften, 1872. 



260 DISEASES OF THE INTESTINES. 

within the duodenum or at the beginning of the jejunum, 
as a rule, are unaccompanied with indicanuria. 

Obstruction of the Large Bowel. The symptoms here 
are usually less violent and appear a little later than in 
the obstruction of the small intestine. Fecal vomiting 
often appears long after the establishment of the occlusion, 
and it may even be absent if the obstacle is situated at the 
beginning of the descending colon or lower down. The 
meteorism is in most instances limited to the lower parts 
of the abdomen and also to the lumbar regions. In occlu- 
sion of the descending colon it may be noticeable that at 
first there is a protrusion in the left iliac region, afterward 
a protrusion of the transverse colon, and ultimately the as- 
cending colon will also become tympanitic. As mentioned 
above, indicanuria will be absent during the first five or six 
days of illness. 

With regard to the determination of the occlusion within 
the lower parts of the colon, Brinton's 1 method, already in 
use over fifty years ago, is very valuable. It consists in 
filling up the bowel with water through the rectum. If 
not more than half a quart can be injected, the obstruction 
must be situated in the upper part of the rectum. If one 
to two quarts can be injected, the obstruction must be situ- 
ated above the sigmoid flexure, in the descending colon, 
or still higher. In case obstruction is situated in the as- 
cending colon four quarts or still more can be injected and 
retained in the bowel. Insufflation of air or carbonic acid 
gas into the rectum will also occasionally show the seat of 
the obstruction, if the latter is situated in the descending 
or the transverse colon, as there will be a filling up with 
gas of the free portion of the bowel up to the obstructed 
point. When the obstruction is located beyond the trans- 
1 Brinton : "On Intestinal Obstruction, " London, 1867. 



ACUTE OBSTRUCTION. 261 

verse colon, however, it will not permit of distinct recog- 
nition by this method. 

C. Recognition of the Different Forms of Acute Obstruction. 
If the diagnosis of acute obstruction of the bowel is not 
always easy, the recognition of the special anatomical 
lesion underlying it is still more difficult. In many in- 
stances an exact anatomical diagnosis will not be possible 
and we will have to be satisfied with a probable conjecture. 
In some cases, however, the exact determination of the 
etiological factor underlying the obstruction will be possi- 
ble. The following groups of acute obstruction of the 
bowels can be clinically differentiated : 

1. Acute Incarceration of the bowels in hernias (also in- 
ternal hernias, in slits of the omentum, mesentery, or di- 
verticula), in strangulation by bands or twists of the bowel, 
is most frequent between the ages of twenty and forty. 
It occurs more often in males than in females. There is 
often a previous history of peritonitis, of hernia, or of acci- 
dents (contusions). The onset of the disease is sudden. 
The pains are severe. Yomiting is present from the start, 
becoming stercoraceous later on. Collapse is marked. 
Tenesmus is absent. Physical examination of the abdo- 
men gives, as a rule, negative results. 

2. Volvulus most often involves the sigmoid flexure and 
can then be easily recognized. Volvulus of the small in- 
testine, which occurs very rarely, cannot be differentiated 
clinically from incarceration. The rotation of the bowel 
around its axis is either complete (360°) or incomplete 
(half rotation, 180°). In the first instance there is total 
occlusion, while in the latter the intestinal lumen is at first 
partially pervious. Volvulus is more common in males 
than in females in the proportion of four to one, ard occurs 
principally late in life, usually between forty and sixty. 



262 DISEASES OF THE INTESTINES. 

There is usually an antecedent history of chronic constipa- 
tion. The onset of the disease is sudden. The pain ordi- 
narily is intermittent. Vomiting may be absent at first and 
later on occurs intermittently. Constipation is almost ab- 
solute and grows worse after the use of aperients. There 
is pronounced meteorism. The sigmoid flexure can oc- 
casionally be felt as a tumor. Only moderate amounts of 
water can be injected into the rectum. 

3. Intussusception occurs very frequently in early child- 
hood. The onset is sudden, the pains appear early, are 
colicky in character and come in paroxysms. There are 
marked tenesmus and bloody evacuations. The collapse 
is not pronounced. The invaginated coil may be acces- 
sible to palpation and then appears in the form of a tumor 
of egg-size or somewhat larger, this occurring in about 
fifty per cent of the cases. Meteorism develops in con- 
junction with peritonitis. 

4. Obturation of the Intestine by Gall Stones, Enteroliths, 
or Foreign Bodies. Obstruction by gall stones occurs chiefly 
in women and is more frequent at an advanced age. A pre- 
vious history of gall stones or a preceding attack of jaun- 
dice, pains in the region of the liver, and swelling of this 
organ are points which aid in the diagnosis. Obstruction 
by gall stones usually occurs in the small intestine; the 
symptoms, as a rule, are less severe than in other forms 
of ileus. The collapse is not pronounced or may be en- 
tirely absent. Flatus may occasionally be passed, copious 
vomiting of bile may be present. If the gall stone is situ- 
ated in the lower portion of the ileum the vomiting may 
later become stercoraceous. Occasionally the stones can 
be palpated through the abdomen and felt as a hard mass. 
Meteorism is generally not highly developed. In some 
instances there is diarrhoea with admixture of blood, the 



ACUTE OBSTRUCTION. 263 

latter being due to abrasions of the intestinal mucosa pro- 
duced by friction of rough gall stones. 

The recognition of an enterolith as the cause of obstruc- 
tion is very difficult and possible only when small frag- 
ments of a fecal calculus have previously been found in the 
dejecta. The seat of obstruction is as a rule then in the 
large bowel, the latter being the place where enteroliths 
develop. 

Obstruction by foreign bodies will be recognized by the 
previous history ; often also, especially if they are of a 
metallic nature, by a Koentgen picture. An accumulation 
of cherry pits or plum stones may also cause an obstruc- 
tion and will likewise be recognized by the previous 
history and by the presence of some of them in the de- 
jecta. 

Hardened fecal matter will very rarely give the picture 
of obstruction. This will occur only in very weakened in- 
dividuals and in persons with spinal trouble. In these 
cases the rectum and colon will be found filled with greatly 
hardened scybala. If a stricture or a tumor exists within 
the intestine and narrows its lumen, an accumulation of 
fecal matter above the stricture gives rise to acute ob- 
struction. 

5. Dynamic Ileus. Obstruction due to paralysis of a 
segment of the bowel can be recognized only with great 
difficulty. Often there has been a preceding laparotomy 
or some operation on the genital organs in the female or 
a history of a replaced hernia. 

With regard to the recognition of the different forms of 
intestinal obstruction the following table, which gives the 
frequency of the principal symptoms in the various forms 
of obstruction, may be of assistance. 

Among two hundred and ninety -five cases of acute ob- 



264 



DISEASES OF THE INTESTINES. 



struction of the bowels collected in literature and minutely 
examined by K. Fitz * of Boston, the symptoms were as 
follows with regard to the different groups of obstruction : 



Pain 

Nausea and vomiting. . . 

Fecal vomiting 

Tympanites 

Tumor 

Visible coils 



Strangu- 


Intussus- 




Gall 


lation. 


ception. 


Twist. 


Stones. 


Per Cent. 


Per Cent. 


Per Cent. 


Per Cent. 


82 


70 


60 


83 


69 


75 


37 


74 


47 


13 


15 


61 


56 


33 


55 


56 


10 


69 




13 


11 




7 





Stricture 
or Tumor. 
Per Cent. 



60 
80 
33 
66 

27 
20 



Prognosis. — The prognosis of acute obstruction of the 
bowel is very serious. According to Curschmann, 2 only 
thirty to thirty-five patients out of one hundred recover 
from this disease. As a rule ileus caused by coprostasis 
or by obturation with gall stones and foreign bodies gives 
the best prognosis. Then come volvulus and intussuscep- 
tion, while incarceration gives the worst prognosis. If in 
the course of ileus deglutition pneumonia or diffuse peri- 
tonitis or perforation of the bowel develops, then the case 
is well-nigh hopeless. Operative intervention, especially 
in cases in which the seat of the intestinal occlusion is 
known, improves the prognosis considerably, but only if 
it is resorted to early . Later, when the complications just 
mentioned arise, not much can be expected from an opera- 
tion. 

Treatment. 

A. Medical Treatment. — Absolute rest is of the great- 
est importance. The patient should be kept in bed and 
told to avoid any abrupt motions. He should not be 

1 R. Fitz : " Transactions of the Congress of Physicians and Sur- 
geons," vol. i., 1888. 

2 Curschmann: "Die Behandlung des Ileus. 
Medicin, Wiesbaden, 1889. 



Congress filr innere 



ACUTE OBSTRUCTION. 265 

allowed to go to the water-closet, but should use a bed- 
pan. With Treves, Graser, ! and others I am for absolute 
rest of the stomach and intestines, i.e., no food whatever 
should be given to patients suffering from acute obstruc- 
tion of the bowels. 

If there is great thirst a teaspoonful of hot water or very 
weak tea may be given every half-hour or hour or a small 
piece of ice may be held in the mouth until it melts, but 
the water should not be swallowed. Neither should any 
stimulants like wine, champagne, or whiskey be given by 
the mouth. In obstruction of the small intestine small 
quantities of a saline solution (about seven to twelve ounces) 
may be injected into the bowel several times during the 
day. If the sickness lasts several days, nutritive enemas 
consisting of milk and egg or of a peptone solution may 
be given in the same way. If, however, the patient is not 
able to retain the enema, considerable quantities of saline 
solution must be injected either subcutaneously or intra- 
venously. 

All writers agree that no cathartic remedies whatever 
should be used, as they increase the peristalsis and there- 
by may cause great harm. A cathartic should be per- 
mitted only in cases in which the obstruction is positively 
due either to gall stones or hardened fecal masses or in 
dynamic ileus. It is, however, of benefit to evacuate the 
lower parts of the bowel by means of an enema. This 
cleans out the rectum, diminishes the feeling of tension to 
a slight extent, and prepares the bowel for the nutrient 
enemas. 

The administration of opium plays a principal part. It 

'Graser: "Behandlung der Darmverengerung und des Darraver- 
schlusses." Penzoldt-Stintzing's "Handbuch der speciellen Therapie 
innerer Krankheiten, " Jena, 1896. 



266 DISEASES OF THE INTESTINES. 

is indicated not only as a means of allaying pain but for 
its soothing action upon the intestinal peristalsis. The 
arrest of the latter may have a direct curative effect, since 
it may promote a return of the partly incarcerated or in- 
vaginated or slightly twisted coil to its normal position. 

In order to secure a prompt action of the drug it is best 
to first give a hypodermic injection of morphine, one-sixth 
to one-fourth of a grain. A short time afterward a sup- 
pository of two-thirds of a grain of opium is administered 
and repeated every three or four hours until the pains are 
kept in abeyance. In cases in which the vomiting is not 
so marked, opium may be given in the form of the tincture 
fifteen to twenty drops every three to four hours. It is 
hardly necessary to say that the opiates should not be used 
too lavishly. Only so much should be administered as is 
absolutely necessary for relieving the pain and quieting 
the violent peristalsis of the intestine. Given in this way, 
opium not only acts as a sedative but also as a stimulant 
on the heart. Patients in deep collapse very soon after an 
injection of morphine become warm, show a better pulse 
and a more normal temperature. The only disadvantage 
of opium is that it slightly masks the true picture of the 
disease. It is therefore best whenever possible first to 
make an exact diagnosis by thorough examination of the 
abdominal viscera by palpation, auscultation, etc., before 
administering it. 

If the symptoms of the disease persist after the admin- 
istration of opium, especially if the tension of the abdomen 
is not relieved and no flatus is passed, it is well to dis- 
continue the remedy for a certain period of time. This 
will enable the physician to judge the situation critically. 

As a further sedative agent applications of poultices can 
be considered. A hot-water bag, a hot plate wrapped up 



ACUTE OBSTRUCTION. 267 

in flannel, or a Japanese warm box, wet packs (Priessnitz) 
are useful. If there are signs of peritoneal inflammation, 
applications of ice or of very cold poultices are prefer- 
able. 

Lavage of the stomach was first recommended in this 
disease by Kussmaul and Calm. 1 This procedure is of 
benefit if the obstruction is situated high up in the small 
intestine. It empties the stomach, relieves the vomiting, 
and also decreases the abdominal tension. There is no 
doubt that this therapeutic measure is sometimes crowned 
with success in appropriate cases. As a striking instance 
of the efficacy of this mode of treatment the following case 
may be reported : 

E. K., thirty -five years old, had always been well, when 
he suddenly became critically ill with violent abdominal 
pains and constant vomiting. For three days there was 
no evacuation of the bowels nor was the patient able to 
pass any flatus. On examination I found his abdomen 
considerably distended and tense. The stomach could be 
mapped out and was considerably dilated, the greater cur- 
vature extending a hand's width below the navel. On pal- 
pation there was considerable tenderness all over the= 
abdomen. The pulse was quite frequent (110) and weak, 
temperature 96.5° in the mouth, the extremities were cold. 
The face showed an expression of great suffering. There 
were almost continuous hiccough and now and then vomit- 
ing of a watery, turbid, somewhat brownish-looking liquid 
with fecal odor. On introducing the tube over a quart of 
liquid of the same character was obtained. The stomach 
was then washed out with several quarts of water until the 
fluid returned quite clear. The patient felt somewhat re- 
lieved. The vomiting stopped and on the following day 
there was a spontaneous evacuation of the bowels. The 
patient was now able to pass flatus, the distention sub- 

1 Kussmaul-Cahn : "Heilung von Ileus durch Magenaussptilung. '*" 
Berl. klin. Wochenschr., 1884, Nos. 42 and 43. 



268 DISEASES OF THE INTESTINES. 

sided, and he gradually recuperated. For the sake of com- 
pleteness I would add that besides washing out the stomach, 
the treatment consisted in the administration of opium 
suppositories. 

Lavage of the Bowel. Injections of large amounts of 
water into the bowel under considerable pressure are also 
occasionally of benefit, especially in cases of intussuscep- 
tion of the colon or when a foreign body or hardened fecal 
matter is the cause of the obstruction within the large 
bowel. According to Treves, it is desirable to use this 
procedure after anaesthetizing the patient. A considerable 
quantity of water (varying according to the age of the pa- 
tient from half a pint to three quarts) is introduced into 
the bowel by means of an ordinary fountain syringe. The 
fluid is allowed to remain in the colon for at least ten min- 
utes. While injecting the water it is best to have the pa- 
tient in such a position that his head is lowered and his 
pelvis is raised. While the irrigation of the bowels is 
going on the physician should hold his hand upon the 
patient's abdomen and in this way notice any change which 
may occur. 

In intussusception when the tumor can be felt the 
latter will in some instances suddenly disappear, giving 
way to the pressure of the water. Too great force, 
however, should never be used, as this may bring on rup- 
ture of the bowels. Instead of water, injections of warm 
olive oil, which were first recommended by Kussmaul and 
Fleiner, may be used in the same way. Dr. Klubbe l has 
related three cases of cure by means of this method. 

Inflation of tlie Bowel ivith Air or Certain Gases in 
Gases of Invagination. Trastour 2 recommended inflation 

1 Klubbe : British Medical Journal, November 6th, 1897. 

2 Trastour : Bulletin General de Therapie, 1874, p. 107. 



ACUTE OBSTRUCTION. 269 

of the bowel with air by means of a common bellows, to 
which an India-rubber nozzle and rectal tube had been 
attached. The forcible filling up of the bowel with air is 
capable of producing the same effect as the injection of 
water and may free the invaginated portion. Yon Ziems- 
sen ' has recommended the use of carbonic-acid gas, while 
Senn 2 suggested hydrogen gas. Carbonic-acid gas is best 
used in the form of "sparklets," as suggested by Dr. A. 
Rose 3 of New York. Care must be taken not to fill up the 
bowel too quickly and too forcibly. 

Massage. Massage has been recommended by several 
writers. Its use, however, is not entirely harmless. It 
can be of benefit only in cases of obstruction by gall stones 
and fecal matter, but even in these cases extreme care in 
its use is necessary. 

Electricity. Electricity has especially been recom- 
mended by Boudet. Among seventy cases of ileus Boudet 4 
had fifty-three recoveries by this method. The faradic or 
galvanic current may be used. In the application of the 
faradic current one metal electrode of cone shape is in- 
serted into the rectum while another large plate electrode 
is kept over the abdomen for about ten to twenty minutes. 
In using the galvanic current it is necessary to have a 
special rectal electrode, which is constructed in such a way 
that water running through it forms the conductor, so as 
to avoid burning the mucosa. The other electrode is placed 
over the abdomen. The negative pole should be inside. 
The strength of the current should vary from ten to fifteen 
milliamperes. The duration of the treatment should be 
twenty to twenty-five minutes. 

1 Yon Ziemssen : Archiv fur klinische Medizin, Bd. 33, Heft 3 and 4. 

2 Nic. Senn: "Intestinal Surgery, " Chicago, 1889, p. 244. 

8 A. Rose : New York Med. Journal, 1900, i., p. 47. 

* Boudet: Progres Medical, February 7th and 14th, 1885. 



270 DISEASES OF THE INTESTINES. 

Electricity will be of special value in obstruction due 
to hardened fecal matter or in the paralytic form of ileus, 
while in incarceration it is rather contraindicated. 

Puncture. Puncture of the distended bowel has recently 
been recommended anew by Curschmann, 1 von Ziemssen, 
and others. According to Curschmann, puncture of the 
intestine is performed in the following way : A long aspi- 
rator needle of thin calibre (like that of a Pravaz syringe) 
provided with a stopcock is thrust into the abdomen over 
a prominent coil of the intestine. A piece of rubber tub- 
ing is then connected with the outer end of the needle ; 
the free end of the latter is inserted into a bottle filled with 
water, which is turned upside down in a basin likewise 
filled with water. The stopcock of the aspirating needle 
is now opened and the gas escaping from the intestinal 
coil appears in bubbles rising to the upper part of the 
bottle, displacing the water. There is no doubt that con- 
siderable temporary relief can be afforded by this mode of 
procedure, as it lessens the feeling of tension. Occasion- 
ally it may also have a direct curative result. Thus 
Curschmann reports three cures by this method. Punc- 
ture, however, is not entirely free from danger. In cases 
in which the intestine is already partly paralyzed, the 
opening after the withdrawal of the needle may not entirely 
close and intestinal gases and contents may continue to 
ooze out and cause peritonitis. 

Most surgeons of note are against this procedure, as it 
lacks precision and is not free from danger. Thus Treves, ' 
Kocher, 3 and Graser 4 are all opposed to its employment. 

1 Curschmann • Deutsche med. Wochenschrift, 1887, No. 21. 

2 Treves: "Intestinal Obstruction, " New York, 1899, p. 471. 

3 Kocher: "Mittheilungen aus den Grenzgebieten der Medizin," 
1898, Bd. 4, p. 2. 
4 Graser: Penzoldt-Stinzing's "Handbuch, " Bd. 4, p. 562. 



ACUTE OBSTRUCTION. 271 

Sad experiences with puncture have been reported by 
Frentzel, 1 Fiirbringer, 2 Hoffmann, Korte, 3 and Graser. 
The latter observed the appearance of fecal matter and 
consecutive peritonitis from such an opening. He con- 
siders puncture permissible only if the patient absolutely 
refuses an operation. 

Mercury (Mercurius Vivus). The internal administration 
of pure mercury in tablespoonful doses was highly es- 
teemed as a remedy for ileus by the old physicians. When 
all resources had been exhausted without success, mercury^ 
was given as an ultimum refugium. Even nowadays many 
physicians are convinced of its efficacy. The use of mer- 
cury in incarceration, strangulation of the bowel by twists 
or bands, intussusception, is not permissible, as it does 
real harm. In ileus in consequence of coprostasis or in 
dynamic ileus, mercury may be employed if all other rem- 
edies have proven futile. Its effect consists in the pene- 
tration of the mercury into the accumulated fecal matter, 
thus softening it. 

All the enumerated internal methods of treatment must 
be applied, first, in cases in which the obstruction is due 
either to gall stones or to foreign bodies or fecal accumu- 
lation or volvulus of the sigmoid flexure; secondly, in cases 
in which the exact diagnosis as to the kind of obstruction 
is not settled, and which are not of a very severe type. In 
all other varieties of intestinal obstruction and even in the 
types just mentioned, after the failure of the medicinal 
measures at hand, an operation should be resorted to. 

'Frentzel: Deutsche Zeitschr. f. Chirurgie, Bd. 33. 

2 Fiirbringer : Verhandl. des 8ten Congresses f. innere Medicin, 1889. 

:; Korte : Ibidem. 



272 DISEASES OF THE INTESTINES. 

B. Surgical Treatment. 

Treves, the greatest authority on intestinal obstruction, 
says: "There is one measure for the treatment of acute 
intestinal obstruction, and that is by means of laparotomy. 
The operation should be performed at the earliest possible 
moment, as soon indeed as the diagnosis is reasonably 
clear. In case of acute abdominal trouble in which the 
diagnosis is not clear, the better and safer course is to 
operate." This view is now generally accepted by physi- 
cians as well as surgeons. 

As mentioned above, obturation, ileus, and volvulus of 
the sigmoid flexure are the only groups of intestinal ob- 
struction in which medical treatment plays a prominent 
part. The importance of an early operation has been 
shown by Naunyn, who found that among two hundred 
and eighty -eight cases of ileus operated upon, the results 
were the more favorable the earlier recourse was had 
to surgical intervention. In those cases in which the 
operation was performed during the first two days of 
sickness recovery took place in seventy-five per cent. 
During the third day and still later there were only 
thirty -five to forty per cent of recoveries. 

A similar view is expressed by Gibson, ' who dealt par- 
ticularly with acute intussusception. Among one hundred 
and forty-nine cases of this affection he found an average 
mortality of fifty -three per cent. The first and second days 
showed mortality inferior to the general mortality, while 
the four succeeding days showed a steadily increasing mor- 
tality, in each instance greater than the average. With 
regard to treatment by inflation of the bowels by enemata 

1 C. L Gibson : "Mortality and Treatment of Acute Intussusception, 
with Table of 239 Cases. " Medical Record, July 17th, 1897. 



ACUTE OBSTRUCTION. 273 

of fluids (or air) Gibson says : " It is probably not an ex- 
aggeration to say that if all cases of intussusception were 
treated on the tmset, or say within forty-eight hours, by 
abdominal section, without any previous attempt at re- 
duction, the mortality, while still considerable, wrould in all 
probability be very much less than the present figures." 
Gibson believes that injections should be tried only on 
the first or at the latest on the second day. 

In the discussion on intestinal obstruction which took 
place at the New York State Medical Association, 1 all the 
speakers (Parker Syms, E. D. Ferguson, George D. Stew- 
art, J. W. Gouley, J. D. Kushmore, LeEoy J. Brooks, 
John F. Erdmann, Fred. H. Wiggin, and H. O. Marcy) 
were in favor of surgical treatment and for early interven- 
tion. J. D. Rushmore says : ' "I have no hesitation in 
affirming that in competent hands operation for intestinal 
obstruction would not have a mortality above twenty per 
cent. In my personal experience, including over one hun- 
dred and ten operations, the mortality has been nearly forty 
per cent. In the last thirty cases there have been six 
deaths." Wiggin 3 considers that operations performed 
w r ithin the first forty -eight hours will give a mortality of 
22.2 per cent. 

Inasmuch as the question of operation has to be dealt 
with in each case of intestinal obstruction, it is advisable 
to have the opinion and advice of an expert surgeon right 
at the start of the disease. The physician and surgeon 
should act together, the first watching the symptoms 
carefully and making the diagnosis, the second prepared 
to resort to surgical intervention as soon as it is demanded. 

1 Transactions of the New York State Medical Association, 1898. 
2 J. D. Rushmore: Ibidem. 

3 F H. Wiggin; Da Costa's "Modern Surgery," p. 644. 
18 



274 DISEASES OF THE INTESTINES. 

In this way the number of recoveries will be greater in the 
future than it has been in the past. 

The operation consists in making an abdominal incision, 
finding the seat of the lesion, and removing the obstacle if 
possible. If not, an enterostomy is performed in the most 
distended coil of intestine which is then attached to the 
abdominal wall. The fecal matter and the gases thus find 
an outlet through this opening. Enterostomy is also re- 
quired in all cases in which the portions of the intestine 
are already found gangrenous. Treves says that this oper- 
ation (enterostomy) could be avoided in acute intestinal 
obstruction if the abdomen were opened at the very earliest 
possible moment. Every hour delayed adds to the grav- 
ity of the case. " The earlier the operation the less the 
need for enterostomy. Laparotomy should be performed 
at an early enough period to render an opening into the 
bowel unnecessary." 

CHRONIC INTESTINAL OBSTRUCTION. 

Etiology. — Chronic intestinal obstruction may be caused 
by the same factors which produce acute ileus if they do 
not occlude the entire lumen of the bowel but leave part of 
the canal open. Besides, obstruction of the intestine is 
frequently occasioned by strictures resulting from preced- 
ing ulcers or from new growths. The latter, benign as 
well as malignant, are liable to give rise to occlusion even 
if they do not occupy the entire circumference of the bowel, 
by simply obtruding part of the canal at the site of their 
greatest development. Strictures caused by ulcers much 
more frequently involve the large than the small intestine. 
According to Treves, they are found six times as often in 
the large bowel as in the small one. 

While formerly dysentery was believed to be the cause of a 



CHRONIC OBSTRUCTION. 275 

large number of these intestinal strictures, Woodward ' has 
shown that this view is not supported by facts. Among 
the many autopsies on patients with chronic dysentery 
which the latter had an opportunity to observe, there was 
not one case of dysenteric stricture of the intestiue. 
Nothnagel agrees with Woodward. On the other hand, 
tuberculous ulcers of the intestine which were regarded 
as only rare causes of intestinal stricture have recently been 
found to produce strictures quite frequently. Koenig 2 laid 
stress upon the frequency of constricting tuberculosis of 
the intestines. The latter may exist even if tuberculosis 
in other organs is absent. Ulcers of typhoid fever very 
rarely if ever cause strictures, and this also applies to the 
small follicular ulcers. Syphilitic ulcers on the contrary 
produce strictures quite often. All kinds of strictures are 
met with most frequently in the lower portion of the colon, 
principally in the rectum. Sometimes they lie just above 
the anal region and can then be very easily discovered. 

Symptomatology. — The symptoms and the course of the 
disease vary considerably, and greatly depend upon the 
cause of the obstruction. Thus, clinically, the benign 
growths must be differentiated from the malignant ones 
(in which the obstruction is caused by cancer). The pic- 
ture which the intestinal obstruction as such produces 
will, however, be pretty much the same. A stenosis which 
is not very much pronounced may give rise to no symp- 
toms whatever. It is therefore quite evident that the dis- 
ease may exist for some length of time before manifesting 
its presence. 

In typical cases of chronic intestinal obstruction the 
onset is slow and insidious. The patient at first notices 

1 Woodward : Loc. cit. 

2 Koenig: Deutsche Zeitschrii't fur Chirurgie, 1891. 



276 DISEASES OF THE INTESTINES. 

slight digestive disturbances, some discomfort in the 
abdomen which gradually changes into real pain, and 
slight constipation. The latter as a rule quickly becomes 
worse. Mild aperients which a short while before were 
efficient refuse to act, and the patient is obliged to resort to 
stronger cathartics ; at times even these will fail to work. 
Frequently constipation suddenly alternates with an attack 
of severe diarrhoea, which may last several days and be 
followed by another period of obstinate constipation. In 
some instances the color and form of the fecal matter will 
be an indication of the seat of the stenosis. It is gener- 
ally believed that pipestem-like or tape-like motions indi- 
cate a stricture in the colon. According to Treves, 1 how- 
ever, this sign is of very little value, as in the great 
majority of cases the sphincter muscle is the originator 
of these peculiar shapes. Diarrhoea may also occasionally 
occur. It is sometimes quite obstinate, especially if the 
stenosis is situated in the large bowel. An admixture of 
blood or pus in the dejecta is occasionally met with and is 
due to ulcerative processes taking place at the seat of the 
stricture or immediately above it. 

Vomiting is not a very marked feature at first, but later 
on, occurs more frequently. When the obstruction, how- 
ever, becomes complete, vomiting is a prominent symp- 
tom and may assume a stercoraceous character. 

The situation of the obstruction has much influence upon 
the clinical picture of the disease. If the stenosis is situ- 
ated in the duodenum above Vater's papilla, the symptoms 
will resemble those of stricture of the pylorus. Ischochy- 
mia, vomiting, nausea will be the prominent features. A 
stenosis of the duodenum below Yater's papilla, although 
presenting symptoms similar to those of stricture of the 
1 Treves : Loc. cit. , p. 395. 



CHRONIC OBSTRUCTION. 277 

pylorus, will be recognized by the more or less constant pres- 
ence of large amounts of bile in the stomach. The farther 
down in the small intestine the obstruction is situated, the 
less pronounced are the gastric symptoms and the more 
marked the intestinal manifestations (less vomiting or 
nausea, more constipation, colicky pains). If the stenosis 
is situated in the lower portion of the ileum or in the colon 
no gastric symptoms are as a rule present. The appetite 
is good, there is no nausea, and the principal features are 
obstinate constipation, sometimes alternating with diar- 
rhoea and frequent attacks of colicky pains. 

Condition of the Abdomen. The abdomen may present a 
normal appearance when the stenosis is situated in the 
upper portion of the small intestine, although in some of 
these cases there may be a protrusion of the upper part 
of the abdomen. If the site of obstruction is in the lower 
portion of the small intestine or in the large bowel, then 
some distention of the abdomen is usually noticeable, espe- 
cially after the disease has advanced considerably. Above 
the obstruction there is always distention and hypertro- 
phy of the bowel. The latter is a manifestation of the 
attempt which nature makes in order to overcome the diffi- 
culty. The intestines above the stenosis act with greater 
force in order to propel the contents through the narrow 
passage. 

The contraction of the bowel above the affected area 
often assumes a tetanic type and is then painful. Such 
violent tetanic contractions are often visible through the 
abdominal wall, and by propelling large amounts of liquids 
and gases through the narrowed lumen, give rise to gur- 
gling and bubbling sounds audible at a distance. Treves 
thus describes the picture which this violent peristalsis 
manifests : " The surface of the abdomen becomes uneven, 



278 DISEASES OF THE INTESTINES. 

a rounded elevation appears in one place and depressions 
appear in another. They produce an aspect comparable 
to that of a relief map of a hilly country. Slowly the 
hill-like elevation sinks and vanishes and out of the 
shallow valley appear fresh eminences which rise up and 
move along beneath the skin. The movements are slow 
and attended by colicky pains, and by more or less of 
rumbling and gurgling sounds." . . . "The same coil 
appears again and again and can often be quite definitely 
recognized. Although as a rule the contracting coils of 
the small intestine are of considerably smaller size than 
those of the large bowel, occasionally even the small intes- 
tine may assume such dimensions that it cannot be differ- 
entiated from the large bowel." 

Meteorism is often present. If the obstruction is situ- 
ated in the lower portion of the colon or in the rectum, the 
meteorism is at first restricted to the large bowel, the dis- 
tention then being pronounced along the course of the colon 
at both sides of the abdominal wall and in the epigastric 
region. The lower part of the abdomen and also the re- 
gion of the navel may be free from meteorism. If the 
stricture is situated in the lower portion of the ileum or 
csecum, the lumbar regions of the abdomen are quite lax, 
while the distention is more or less pronounced in the na- 
sogastric and hypogastric regions. 

After having described the symptoms of chronic intesti- 
nal obstruction in a general way it will be useful to point 
out separately the characteristics of some special forms 
which occur more or less frequently. 

Chronic intussusception may develop either after an acute 
attack or begin slowly and insidiously without at first giv- 
ing rise to any marked symptoms. It is most frequently 
found in the ileo-csecal portion. Pain occurs during the 



CHRONIC OBSTRUCTION. 279 

progress of the disease and is usually of a paroxysmal 
character. Attacks of pain may appear several times a 
day or once in twenty-four hours. Occasionally days and 
even weeks elapse between the paroxysms. As a rule the 
intervals between the attacks grow shorter as the disease 
advances. In some cases there is almost continuous suffer- 
ing with occasional exacerbations. Vomiting seldom oc- 
curs and is certainly not a marked feature. A tendency to 
diarrhoea very often exists. The bowels may be normal or 
constipated for a while and then become loose, or there 
may be persistent diarrhoea. Blood is very often passed 
with the stools and tenesmus is occasionally present. 

On examination of the abdomen by palpation a tumor is 
found in almost half of the cases. The nature of the tumor 
corresponds to that found in acute intussusception de- 
scribed above. Occasionally a tumor can be felt in the rec- 
tum when the intussusception involves the lower portion of 
the large bowel. In rare instances the invaginated portion 
is separated from the bowel by necrotic processes, and may 
then appear in the movement. While this event may in 
rare instances lead to perfect recovery (the other portions 
of the bowel growing together and the lumen thus being 
restored), in the greater majority it causes death through 
perforation, rupture of the intestinal walls, and general 
peritonitis. 

Chronic Obstruction Due to Fecal Accumulation. This 
variety of intestinal obstruction is more common in fe- 
males than in males and is usually met with in more ad- 
vanced age and in patients suffering from hysteria and 
brain troubles. As a rule, the patients have already long 
before been subject to habitual constipation ; usually many 
days elapse without an evacuation of the bowels. From 
time to time enormous quantities of fecal matter are passed 



280 DISEASES OF THE INTESTINES. 

by artificial means. Later on the symptoms of constipa- 
tion grow more intense. The abdomen becomes distended 
and it is much more difficult to secure an evacuation even 
by artificial means. As a rule the patient is tormented by 
eructations and flatulence. His appetite is poor; he has 
a bad taste in his mouth and frequently his breath has an 
unpleasant odor. Headache, vertigo, and a general tired 
feeling are often encountered. 

These symptoms, as well as the marked unhealthy ap- 
pearance of the skin, are most probably due to intestinal 
auto-intoxication. Certain chromogens, the products of 
decomposition, are absorbed from the bowel and give rise 
to this peculiar discoloration of the skin. The conjunctivae 
also are often yellow. A further symptom due most prob- 
ably to the same process of auto-intoxication is the rise of 
temperature which is often present. If the distention of 
the abdomen is very marked, a feeling of oppression in the 
chest and palpitations of the heart are experienced. 

Fecal accumulation sometimes causes pressure upon the 
lumbar or sacral nerves and gives rise to discomfort in 
the genital organs or to pain in the thigh radiating down 
the entire leg. Distended coils may be visible through 
the abdomen and there may be much rumbling and gur- 
gling heard after constipation has lasted a long period. 
This symptom is, however, not so marked here as in cases 
of stricture of the intestine. Vomiting may occur and even 
become stercoraceous. Slight colicky pains are felt over 
the abdomen, but as a rule they are not intense. 

The symptoms having advanced to an extreme degree, re- 
lief may ensue either spontaneously or after resort to differ- 
ent procedures which serve to evacuate the bowels. Occa- 
sionally, however, an evacuation of the bowel cannot be 
obtained and the patient develops all the symptoms of an 



CHRONIC OBSTRUCTION. 281 

unyielding obstruction which may be fatal. Often there 
are attacks of obstruction following each other at certain 
intervals. The narrowed lumen of the bowel most prob- 
ably becomes entirely occluded or blocked by a piece of 
hard fecal matter, which completely fills it and cannot 
move in either direction. Sometimes the abrupt stoppage 
may be due to some bending or kinking of the distended 
bowel. 

In almost all cases of obstruction by fecal masses 
a tumor can be palpated usually in some portion of the 
colon. The tumor is caused by the fecal accumulation. 
The caecuru, the hepatic and the sigmoid flexures are the 
places where the tumor is most often encountered. Such 
a fecal tumor feels hard and uneven ; sometimes it has a 
globular shape. As a rule it is not painful on pressure.- 
Sometimes it is possible to change the shape of the 
tumor by pressure. This is the best proof of its fecal 
character. Sometimes, however, pressure does not give 
rise to any change in the configuration of the mass if 
the fecal matter is very hard. The best sign of its fecal 
nature is the change in form after repeated irrigations of 
the bowel. In some rare instances the fecal accumulation 
occupies the greater part of the abdominal cavity and gives 
the impression of one immense tumor of very hard consist- 
ency. I have seen two such cases in patients suffering 
from grave melancholia. Here also after repeated irriga- 
tions of the bowel and administration of cathartics the tu- 
mor gradually becomes smaller and ultimately disappears. 

Stricture of the Rectum. — In this condition as a rule there 
are at first merely symptoms of constipation ; later on these 
become more obstinate, requiring stronger cathartics. The 
patient now begins to complain of congestion of the head, 
anorexia, nausea, cold feet, and sometimes of disagreeable 



282 DISEASES OF THE INTESTINES. 

sensations in his limbs ; still later there is diarrhoea which 
may persist as such or alternate with constipation. Off 
and on muco-purulent material appears with the dejecta. 
A burning sensation is often felt in the rectum, and tenes- 
mus is frequently present. Hemorrhoids and prolapse of 
the rectum often accompany the stricture. 

Digital examination of the rectum often reveals a ste- 
nosed area in its lower part. The finger is either not able 
to pass any farther than a few centimetres (five to six) 
above the anus or it meets with a resistance which it can 
overcome. Contrary to spasm of the rectum which yields 
completely after the finger has succeeded in passing the 
constriction, in stricture of the rectum the pressure of the 
narrowed lumen exerted upon the finger remains constantly 
the same. 

Most of the strictures are situated about five to six centi- 
metres above the anus, seldom higher up. In the latter in- 
stance the examination must be made with a bougie or with 
a rubber tube which is not too soft. In order to determine 
the exact nature of the stricture it is always best to make 
a visual examination of the rectum by means of a specu- 
lum. 

Complications. — No matter to what cause the intestinal 
obstruction is due, in the protracted course of the disease 
several complications are liable to occur, although here 
less often than in acute obstruction. Above the stenosed 
area ulcerations of the bowel may take place and perfora- 
tion may occur, giving rise to general peritonitis. Occa- 
sionally circumscribed peritonitis may ensue in a similar 
manner and lead to an abscess surrounded by adhesions. 
Such an abscess may rupture through the abdominal wall 
and under favorable conditions (if communicating with 
the intestinal lumen) form a fecal fistula. In many in- 



CHRONIC OBSTRUCTION. 



283 



stances the patients gradually waste away and die in con- 
sequence of thrombosis of the crural vein and decubitus. 

Course and Prognosis. — The 
duration of chronic intestinal 
obstruction depends largely 
upon the nature of the partic- 
ular affection and upon the 
degree of the obstruction. If 
there are no complications and 
the patients lead a perfectly ra- 
tional life (with regard to diet 
and treatment) the condition 
may last a number of years. In 
other cases the symptoms of 
intestinal obstruction rapidly 
progress and life is then of 
short duration unless something 
radical is done. 

Diagnosis. — The diagnosis of 
chronic intestinal obstruction is 
warranted by the presence of 
gradually increasing symptoms 
of constipation, and attacks of 
intestinal colic with a temporary 
stoppage of the bowels follow- 
ing each other at not too great 
intervals. The acute attack of 
obstruction in these cases of 

chronic intestinal stenosis is as a rule much milder than 
in acute occlusion of the bowel not due to a chronic con- 
dition. In the chronic form there is either no collapse at 
all or it is but slightly marked. Increased intestinal peri- 
stalsis is often encountered in the chronic form, especially 




t 






Fig. 38.— Patient M. with Chronic 
Intestinal Stenosis (Stricture of 
Descending Colon), Showing the 
Barrel-shaped. Abdomen. 



284 DISEASES OF THE INTESTINES. 

during an attack of obstruction, while in the acute form 
this is quite rare and, if present, less pronounced. The 
barrel-shape of the abdomen is often present in chronic 
intestinal stenosis and is of diagnostic value (Fig. 38). 
The different forms of intestinal obstruction can be rec- 
ognized by their varied symptoms which have already 
been described above. 

Treatment. — The treatment comprises the management 
of the disease during the intervals and during the attacks. 
During the intervals the following rules are of importance : 
The diet should exclude all substances which give large 
residue of fecal matter or which are of an irritating charac- 
ter. Thus green vegetables, salads, fruits, vinegar, mus- 
tard, pepper, must be strictly forbidden. Milk and milk 
soups, eggs, tender meats without too much fat and with- 
out tendons, butter, toasted bread or plain white bread 
well baked, farina, rice and sago, well cooked, are permis- 
sible. The patients should eat frequently and not too 
much at a time. Cold drinks should be avoided. Atten- 
tion must be paid to the patient's taking a sufficient quan- 
tity of food. 

The bowels must be kept in working order. It is abso- 
lutely necessary to secure one evacuation daily. Massage, 
electricity, and the usual mild cathartics (like magnesia 
sulphate, rhubarb, cascara sagrada, syrup of figs) may be 
used. Injections of water or oil into the bowel are also 
of benefit. When diarrhoea is present it should not be 
checked unless the patient is greatly debilitated. Even 
then only mild astringent remedies are permissible. Often 
even during periods of diarrhoea, when not very large evac- 
uations take place, a mild cathartic (like castor oil or 
Carlsbad salts) must be employed in order to assure a 
thorough cleansing of the bowel. 



CHRONIC OBSTRUCTION. 28o 

During the attack of intestinal colic warm fomentations 
over the abdomen should be applied. If these be insuffi- 
cient, the narcotic remedies are in place. Opium alone or 
opium with belladonna may be given either by the mouth 
or in suppositories. Here also it is necessary to produce 
a sufficient evacuation of the bowel, which is best done by 
rectal injections. If there are great distention of the abdo- 
men and vomiting, gastric lavage is beneficial. Cocaine 
in doses of one-third to one-half grain, or menthol one 
grain three times daily, will allay the vomiting. If there 
is a real attack of acute obstruction this must be treated 
in the same manner as primary acute intestinal obstruc- 
tion, described above. 

If the stenosis involves the upper portion of the small 
intestine, lavage will play an important part in allaying 
the symptoms temporarily. Chronic fecal impaction re- 
quires the application of massage and also of electricity, 
as described in the chapter on constipation. Sometimes 
the hardened scybala will have to be removed from the 
rectum by artificial means. For this purpose the sphincter 
is first dilated and the fecal masses are removed with the 
fingers or with a spoon-shaped instrument. If there is a 
blocking of the passage higher up in the colon, strong 
cathartics (croton oil) may be administered. Metallic 
mercury has also been advantageously used in these in- 
stances. 

Strictures of the rectum, excepting those of a cancerous 
nature, can first be treated by dilating them gradually with 
bougies of various size. The rectal bougie of Crede best 
answers this purpose. It is advisable to leave the bougie 
within the stricture for at least fifteen minutes and to 
insert it once every two to three days. If the stricture is 
of a very high degree this method of treatment may be. 



286 DISEASES OF THE INTESTINES. 

inefficient, and then surgical measures will have to be un- 
dertaken. 

Operative Intervention.— Ml types of chronic intestinal 
obstruction, with the exclusion of those caused by fecal 
accumulation and strictures of the rectum, gradually grow 
worse. The above-described modes of treatment are only 
of a palliative nature. For this reason it must be consid- 
ered as a decided advance that surgical means have been 
found fully to remove the obstacle and restore the patient 
to complete health. The procedures which are resorted 
to are various and depend upon the anatomical lesion un- 
derlying the obstruction. 

Malignant growths must be extirpated as early as pos- 
sible and an end-to-end anastomosis of the bowel estab- 
lished. A circular stricture of the bowel (of benign type) 
can be removed by enteroplasty in a similar way as pylo- 
roplasty, namely, by splitting the gut parallel to its axis 
or vertically to the stricture and uniting the edges of the 
incision transversely. Pean 1 has successfully performed 
such operations. Several simple strictures of the bowel 
can be treated in the same way, if they are not too close 
together. If the stricture is of a tubular form or if it is 
of too high a degree, excision of the involved part followed 
by exact coaptation of the divided ends by sutures is best 
done. This operation is greatly facilitated by Murphy's 
button, which makes it possible to unite the two ends of 
the severed bowel rapidly without losing too much time 
in the suturing. 

In cases in which the stricture cannot be excised nor 

otherwise remedied, or in any other form of obstruction of 

the bowel which cannot be removed, the bowel just above 

the stricture is united to the bowel below it and a short 

1 Pean . Bulletin de l'Academie de Medecine, 1890, p. 856. 



CHRONIC OBSTRUCTION. 287 

circuit thus established. This is likewise best accom- 
plished by Murphy's button or by McGraw's elastic 
ligature. 

In some strictures of the colon in patients who are already 
quite prostrated, a complete operation of excision or even 
of the formation of a new circuit cannot be performed with- 
out too great risk of life. Here colotomy is indicated, 
being later supplemented by a more radical procedure 
wdien the patient is stronger and in better condition. 

Adhesions should be severed and tumors compressing 
the bowel treated by radical removal. Surgical treatment 
of the intestinal stenosis, affording as it does radical re- 
lief, should be resorted to in every case as soon as the 
diagnosis is positive. The only excuse for subjecting the 
patients to non-operative measures as long as they get along 
in comparative comfort, is the high mortality which surgi- 
cal intervention still furnishes. According to Treves, 1 the 
mortality fluctuates between twelve and twenty per cent. 
It is to be hoped, however, that owing to our advanced 
knowledge of this subject the diagnosis of intestinal ste- 
nosis will be made quite early, and that the patients by 
being operated upon at an early period will show a smaller 
percentage of mortality. 

1 Loc. cit., p. 560. 



CHAPTER X. 

NEKVOUS AFFECTIONS OF THE INTESTINES. 

General Remarks. — The intestinal tract is rich in gangli- 
onic cells and nerves. The plexus mesentericus Auerbach 
and the plexus entericus Meissner accompany it through 
its entire length. The vagus and the splanchnic nerves 
surround the intestinal canal with numerous branches and 
form ramifications with the ganglionic plexus. Although 
a thorough knowledge of the exact action of these different 
nerve groups has not yet been acquired, still we are certain 
that they govern the secretory, absorptive, and motor 
functions of the intestinal canal. 

Secretion seems to be dependent a great deal upon the 
ganglionic plexus, as can be learned from Moreau's ] ex- 
periment. This investigator ligated an intestinal coil and 
severed all the nerves belonging to it. In a few hours the 
coil, thus treated, was found filled with a fluid showing 
amylolytic qualities and containing small quantities of 
albumin. In order to prove the secretory influence of 
nerves upon the intestines Fleischer 2 justly refers to 
the fact demonstrated by Quincke, Demant, and Mass- 
loff, 3 that in man as well as in animals after ingestion of 
food into the stomach, secretion takes place in the lower 
part of the intestine, long before the arrival of the chyme. 

1 Moreau : Central bl. f. die med. Wissensch., 1868, No. 14. 

2 R. Fleischer: "Krankheiten des Darms," Wiesbaden, 1896. 
3 Massloff: " Untersuchungen aus dem physiologischen Institut zu 

Heidelberg, " Bd. ii. 



InERYOUS affections of THE INTESTINES. 289 

This also shows that the nerves of the intestinal tract are 
influenced by reflex action from the nerves of the stomach. 

Yasomotor nerve filaments have also been proven to 
exist in the intestines. Thus stimulation of the splanch- 
nic nerve causes a contraction, while its section is followed 
by dilatation of the intestinal blood-vessels. These vaso- 
motor nerve filaments are undoubtedly also much con- 
cerned with absorption. 

The motor function of the nerves and their influence upon 
peristalsis have been studied in an exhaustive manner by 
Nothnagel, Brahm-Houkgeest, and others, and have been 
described in the chapter on physiology (page 28). 

Although under normal conditions we scarcely perceive 
any sensations within the intestinal tract, we are neverthe- 
less certain that sensory filaments exist in the nervous ap- 
paratus of the intestines. This is revealed by the fact that 
the action of some stimuli of greater intensity than normal 
uj)on the intestinal wall, gives rise to sensations of pain 
and pressure. Thus, a person not accustomed to a coarse 
diet, after ingestion of a large quantity of cabbage and 
beans, for instance, may suffer after six to eight hours 
from pains in the lower part of the abdomen caused by the 
undue irritation of the small intestine. In pathological 
conditions the sensory character of the intestinal nerves 
is evinced very frequently. In fact this is one of the im- 
portant points which we have to consider in almost any 
affection of the intestinal canal. 

The neuroses of the intestine may be classified into : 1, 
motor neuroses ; 2, sensory neuroses ; and 3, secretory 
neuroses. Very often these different neuroses exist in 
combination. Thus, a motor neurosis may exhibit fea- 
tures belonging to secretory or sensory derangements. 

The designation of the neurosis, however, should depend 
19 



290 DISEASES OF THE INTESTINES. 

upon the type most prevalent. All affections of the intes- 
tines in which no anatomical lesion can be discovered are 
classified as neuroses or functional diseases of the intes- 
tines. 

Intestinal neuroses may be primary, i.e., the affection 
emanates from the intestinal tract, or they may be second- 
ary, occurring in connection with nervous manifestations 
in other organs. Etiologically we know that psychical 
influences, mostly of a depressing nature, as fear, fright, 
worry and anxiety, are often the causative factors of intes- 
tinal neuroses. Neurasthenia and hysteria as well as a 
general neurotic tendency are also liable to produce ner- 
vous affections of the intestinal tract. In some instances 
the latter conditions are due to a reflex action originating 
from some other diseased organ (stomach, the genito-uri- 
nary tract, uterus, etc.). 

MOTOR NEUROSES OF THE INTESTINES. 

Diarrhoea. 

Etiology and Symptomatology.— diarrhoea, meaning too 
frequent and usually too watery movements of the bowels, 
is always due to increased intestinal peristalsis. Diar- 
rhoea may be the result of various morbid conditions of the 
intestines, but here we shall describe the form of diarrhoea 
which exists without any apparent anatomical lesions. 

Diarrhoea may be classed under three groups: 1. Ner- 
vous diarrhoea (Trousseau). 1 2. Dyspeptic diarrhoea. 3. 
Stercoral diarrhoea. 

1. Nervous Diarrhoea. Although all the three groups of 
diarrhoea are primarily produced by increased peristaltic 
action of the bowels which is in turn caused by exagger- 
1 Trousseau : "Clinique de 1' Hotel Dieu, " Bd. ii. 



DIARRHCEA. 291 

ated action of the nervous apparatus, this group is desig- 
nated as nervous diarrhoea on account of the predominance 
of the nervous element. Trousseau was the first to de- 
scribe nervous diarrhoea. It originates either through 
undue stimulation of the accelerating peristaltic nerves or 
through some nervous influences which cause a serous 
transudation into the intestinal canal. Frequently both 
factors are probably implicated. 

In many cases the stimulus may emanate from the centre 
and reach the intestinal ganglia through the vagus, the sym- 
pathetic, or the splanchnic. In some cases, however, the 
stimulus affects the ganglionic cells of the intestinal wall 
directly. As characteristic instances of nervous diarrhoea 
we would mention those cases in which there are several 
watery evacuations after a strong emotion, thus after fright 
or fear. Here the stimulus arises in the brain centres 
supervising intestinal motions. While in these instances 
we have to deal with an acute transitory condition, nervous 
diarrhoea can also appear in a chronic form (Nothnagel, 
Peyer ') . There are persons who are attacked with diar- 
rhoea as soon as they are in a place where a toilet-room is 
inaccessible. They may then be seized with abdominal 
pains, tenesmus, and diarrhoea. In other persons, again, 
the mere sight of a water-closet evokes an intense desire 
for an evacuation. 

Occasionally the diarrhoea is preceded by several other 
nervous symptoms, as for instance vertigo, giddiness, con- 
gestion of the head, a sensation of heat all through the 
body, fright, shortness of breath, or palpitation of the 
heart. All these symptoms as a rule rapidly disappear 
after a satisfactory movement. 

1 A. Peyer : "Die nervosen Affectionen des Darmes bei der Neurasthe- 
nic des mannlichen Geschlechts. " Wiener Klinik, 1893, Heft 1. 



292 DISEASES OF THE INTESTINES. 

This form of diarrhoea is found in persons suffering 
from Deurasthenia or hysteria, in debilitated persons, or 
in perfectly healthy people after a more or less pronounced 
shock to the nervous system. Moreover it is met with 
accompanying affections of the spine. Thus Charcot de- 
scribed attacks of diarrhoea appearing periodically in tabes 
dorsalis (intestinal crises). Lastly, nervous diarrhoea may 
exist as a reflex condition in consequence of abnormal proc- 
esses in the neighboring organs (the genito-urinary tract, 
uterus, etc.). 

As an instance of nervous diarrhoea the following case 
may be described : 

N. S., thirty years old, physician, was always perfectly 
well. After a year of hard study and a great deal of care 
and anxiety he had begun to suffer from frequent loose 
evacuations during the last six months. As a rule the 
patient had one or two passages a few minutes after each 
meal. Preceding the evacuation rumbling noises were 
heard in the lower part of the abdomen, while a slight 
feeling of discomfort was experienced. The movements 
were softer and more watery than usual, but did not con- 
tain anything abnormal (no mucus, no undigested food). 
The patient felt perfectly well in every respect, had a good 
appetite, slept well, and had not lost weight. Exami- 
nation of the gastric contents showed the stomach to be 
perfectly normal. The patient was given no medicines and 
was instructed to respond to nature's call in the morning 
and to try to suppress the evacuations after meals when- 
ever possible. For the first few days he succeeded in hav- 
ing no movement after some of the meals, and gradually 
after a few weeks was perfectly free from the desire to 
evacuate the bowels after eating. 

The following case is reported by Fischel : - 

A lady, twenty -three years old, complained of a feeling 

1 F. Fischel : Prager med. Wochenschr., 1891. 



DIARRHOEA. 293 

of oppression, cardiac palpitation, and severe attacks of 
diarrhoea, which appeared periodically independent of the 
quality of the food. The passages were watery and of a 
strong alkaline reaction, smelled bad, and contained 
triple phosphate and considerable amounts of intestinal 
epithelial cells. The examination revealed a retroflexion 
of the uterus. After insertion of a pessary the diarrhoea 
ceased. 

The diarrhoea appearing after exposure to cold and wet 
weather is most probably caused by a reflex emanating, 
from the nerves of the skin and producing hypersemia of 
the intestines. The latter gives rise to transudation into 
the lumen of the bowel and also to increased peristalsis. 
This form of diarrhoea disappears very quickly (in twelve 
to twenty-four hours) and does not produce any anatomi- 
cal changes of the intestinal walls. 

Another group of diarrhoeas takes its origin from an irri- 
tation of the intestinal nerves through some abnormal sub- 
stances contained in the blood. The cathartic action of 
some remedies subcutaneously injected is the best proof 
of this possibility. The diarrhoea occurring in cases of 
septicaemia, of nephritis (with or without ursemic symp- 
toms), and also diabetes is best explained by the theory 
of irritating products circulating in the blood. The diar- 
rhoea accompanying typhoid fever and dysentery in the 
first stage before there has been time for the formation of 
ulcers, is caused by the circulating in the blood of toxic 
elements produced by the pathogenic micro-organisms. 

2. Dyspeptic Diarrhoea. Under dyspeptic diarrhoea may 
be comprised (a) the diarrhoea which appears after certain 
articles of food; (Jb) diarrhoea accompanying abnormal 
conditions of the gastric contents. 

(a) Certain foods may cause mushy or watery evacua- 
tions, as, for instance, fresh fruit, cucumbers, cabbage, and 



294 DISEASES OF THE INTESTINES. 

beets. The liability to diarrhoea from these foods, how- 
ever, greatly varies in different persons. In some people 
milk produces diarrhoea, while in others it is rather con- 
stipating. 

(b) Pronounced conditions of subacidity of the gastric 
contents and still oftener achylia gastrica are associated 
with diarrhoea. Here probably the chyme on account of 
its not having undergone any considerable changes in the 
stomach exerts mechanically too great a stimulus on the 
intestinal wall and thus causes the increased peristalsis. 
Hyperchlorhydria, although rarely, is also found associ- 
ated with diarrhoea. Here the chyme containing too much 
acid most probably produces the increased peristalsis. 

3. Stercoral Diarrhoea. Stercoral diarrhoea means a diar- 
rhoea arising in consequence of too great a stimulus from 
fecal matter. 

Etiology and Symptomatology. — If healthy persons for 
some cause or other become constipated for a certain pe- 
riod of time, the constipation may be followed by diar- 
rhoea. The latter is generally produced by the formation 
of certain gases which chemically or mechanically exert a 
stronger stimulus upon the intestinal peristalsis. Occa- 
sionally hard scybala, as such, irritate the mucous mem- 
brane of the bowel too much and cause increased secretion 
and peristalsis. In stercoral diarrhoea the evacuations are 
as a rule at first formed and solid, later mushy and watery. 
Off and on these watery passages contain several small 
scybala as hard as a stone. Shortly before the appearance 
of diarrhoea the abdomen is often quite bloated and borbo- 
rygmi are heard in the intestines. The patients very fre- 
quently complain of intense headaches. The passage of 
bad smelling flatus affords only temporary relief, while a 
good movement removes almost all the symptoms. Slight 



DIARRHCEA. 295 

gastric symptoms may accompany this condition. A ra- 
tional diet effectually arrests the diarrhoea, but after an- 
other period of constipation it may reappear, and if this 
happens very frequently, intestinal catarrh may be the 
result. 

Diagnosis. — The diagnosis of nervous diarrhoea can be 
made, if anatomical lesions of the intestines can be ex- 
cluded and if the passages do not contain a considerable 
amount of mucus. The special type of the diarrhoea may 
be determined either by the symptoms (nervous diarrhoea 
proper, stercoral diarrhoea) or by an examination of the 
gastric contents (dyspeptic diarrhoea) . 

Progmsis. — Most cases of nervous diarrhoea give a favor- 
able prognosis. In some instances the diarrhoea, origi- 
nally of a nervous origin, assumes a chronic course and 
ultimately produces an enteritis. 

Treatment. — The treatment will vary according to the 
type of the diarrhoea. In nervous diarrhoea proper the 
general condition of the patient must be strengthened and 
the remedies will have to be directed toward this end. 
Arsenic and iron will often prove efficient. In some cases 
the administration of bromides for a few weeks will be of 
great benefit. 

In nervous diarrhoea dependent on a reflex action emanat- 
ing from some other diseased organ, the treatment mast 
be directed toward the primary affection. 

In all cases of nervous diarrhoea, persistent training of the 
intestines in the normal direction must be urged by the 
physician. The patient should be instructed after having 
had his first movement in the morning to refrain from any 
other evacuations of the bowels during this day, answering 
nature's call only when absolutely necessary. In quite a 
number of instances the patient at first continues to have 



296 DISEASES OF THE INTESTINES, 

the desire for an evacuation quite often, but succeeds in 
controlling it. Later on the desire for defecation appears 
less often and at last a normal state is reached. 

In dyspeptic diarrhoea the treatment should be directed 
toward the improvement of the abnormal condition of the 
stomach. Thus diarrhoea due to hyperchlorhydria can be 
successfully checked by bicarbonate of sodium taken in half- 
teaspoonful or teaspoonful doses two hours after meals. 
The diarrhoea resulting from achylia gastrica can be rem- 
edied by a diet rich in vegetable foods, prepared in such 
a manner that they are easily broken up into minute par- 
ticles. Stomachics, intragastric faradization, and gener- 
ally the treatment of achylia gastrica will also control the 
diarrhoea. 

In stercoral diarrhoea an efficient cathartic is the best 
means of checking the diarrhoea. Diarrhoea having its 
cause in a faulty composition of the blood should be rem- 
edied by improving the constitutional condition. If this 
is impossible the treatment must be symptomatic. 

In this connection it may be advisable to describe the 
means we have at our command symptomatically to treat 
diarrhoea, no matter of what nature it may be. The first 
place must be given to opium, a remedy which has stood 
the test of ages and is still the most reliable. It efficiently 
decreases the abnormal peristalsis and probably also di- 
minishes the intestinal secretion. Morphine and the other 
derivatives of opium act in a similar manner, but opium as 
such seems to be preferable in diarrhoeal conditions. Be- 
sides opium there is hardly another remedy efficient to 
check increased intestinal peristalsis, although there are 
several others which may arrest the diarrhoea. Among 
these may be mentioned nitrate of silver, subnitrate and 
salicylate of bismuth, and all the remedies containing tan- 



CONSTIPATION. 297 

nic acid. Another important means in treating diarrhceal 
conditions is heat. A hot-water bag or warm linseed poul- 
tice applied over the abdomen and warm drinks have a 
favorable influence upon the diarrhoea. 

Constipation. 

Synonyms. — Habitual constipation, atony of the bowel, 
constipatio, constipatio alvi, obstipatio. 

Definition. — By constipation is understood a diminution 
in the frequency of evacuations of the bowels. 

General Remarks. — Healthy persons have as a rule one 
evacuation of the bowels daily. Under normal conditions 
3, movement occurs almost always at about the same time 
of the day. The cause of this periodicity lies most prob- 
ably in nervous influences. As mentioned above in the 
chapter on physiology, the contents of the small intestine 
are propelled with comparative rapidity. In the large in- 
testine, however, the prochoresis is very slow. The upper 
rectum and the sigmoid flexure form a reservoir for the 
storage of the fecal matter. Once in twenty-four hours 
through certain nervous influences the faeces are carried 
lower down into the ampulla of the rectum and there is 
then experienced the desire for defecation. This is accom- 
plished voluntarily by relaxing the sphincter ani and by 
exercising a moderate pressure with the abdominal walls 
after more or less deep inspirations. No pain is connected 
with this act and a rather pleasant sensation is felt after 
its accomplishment. 

Even physiologically there is a great variability in the 
number of movements. Some persons have normally two 
or three movements a day all their lifetime, while others 
have only one evacuation every other day or even every 
three days. In both instances there may be no abnormal 



298 DISEASES OF THE INTESTINES. 

sensations whatever and we are thus forced to consider 
them as physiological. Constipation, therefore, should 
signify a condition in which a person has less frequent 
movements than he has been accustomed to. 

In rare instances, however, the number of evacuations 
remains the same, but their quantity diminishes. Thus a 
stagnation of fecal matter in the bowels occurs (copros- 
tasis). This condition is also usually comprised under 
the head of constipation. The quantity of the daily 
evacuation of the bowel varies greatly, depending princi- 
pally upon the diet. A vegetable diet gives voluminous 
stools, while one consisting mainly of meats produces only 
a small quantity of fecal matter. The average quantity 
of fecal matter for twenty -four hours is about 250 c.c. 
While a marked divergence from the above-mentioned fig- 
ure must be recognized as pathological, a small decrease 
of evacuated fecal matter cannot be easily discovered, the 
more so since, according to Woodward, a considerable 
quantity of the fecal matter is made up of micro-organ- 
isms whose number is apt to vary greatly, even under 
normal conditions. 

Constipation may be due to organic lesions of the bowel 
(stenosis of the intestine or catarrhal conditions), or may 
exist without apparent anatomical changes in the intestinal 
tract, and thus be functional in nature. The latter class 
alone is dealt with here c Inasmuch as in the great major- 
ity of these cases of constipation a disturbance in the ner- 
vous apparatus of the intestine may be presumed to exist, 
we discuss constipation in this chapter on intestinal neu- 
roses. 

Etiology. — Habitual constipation may be divided into 
three groups: 1. Constipation due to retarded intestinal 
peristalsis (atony of the bowel). 2. Constipation due to 



CONSTIPATION. 299 

a spasmodic contraction of a certain portion of intestine 
(enterospasrous, spastic constipation). 3. Constipation 
depending upon abnormal conditions of other organs. 

"With regard to the etiology of the first group, namely, 
constipation due to atony of the bowels, which comprises 
by far the greater majority of cases, the following may be 
said : In most instances the constipation is brought on by 
a repeated neglect of nature's calls. Thus, young girls 
while in school suppress the desire for defecation out of 
bashfulness, which gives rise at first to irregularity of the 
bowels and later on to constipation. The mental state is 
also responsible to a great extent for the causation of this 
trouble. 

It is not among the working class that constipation is 
most frequently found, but among the wealthier classes. 
This shows that the mode of living has much to do with 
this affection. If we would go a little more into detail 
and try to analyze cases of chronic constipation, we would 
learn that the patient had perhaps at first a great deal of 
worry or of mental strain. At that time his bowels first 
became sluggish and after a while the affection became 
more developed. The patient experienced more and more 
difficulty, began to take drugs, and after a short time was 
not able to have a movement without medicine. 

Often we find that after an acute gastric catarrh there 
was at first a little diarrhoea, which after a few days 
changed into constipation. After a short time this would 
have disappeared of itself, if the patient in his haste to have 
a movement had not resorted to cathartics, thus upsetting 
again the normal state of the intestinal tract, in conse- 
quence of which chronic constipation developed. Very 
frequently the patient has some trouble, perhaps a head- 
ache, and thinks the stomach is disordered, and begins 



300 DISEASES OF THE INTESTINES. 

to live on a one-sided diet, avoids vegetables, butter, fat 
— all substances which excite the peristaltic action of the 
bowels— and then constipation arises and assumes a chronic 
form. 

In a limited number of cases the retarded intestinal 
peristalsis is due to a real muscular weakness of the 
bowel, the intestinal muscularis being much thinner 
than normally. Nothnagel observed some cases in which 
at the autopsy the muscularis of the large bowel measured 
in thickness 0.12 to 0.25 mm., while normally it ought 
to be 0.5 to 1 mm. In these cases the muscular devel- 
opment of the entire body was poor. It will therefore be 
easily seen that such rare conditions cannot be recognized 
during life. 

In former years the opinion prevailed that chronic consti- 
pation gives rise to the developement of numerous nervous 
affections (neurasthenia, hypochondriasis, hysteria, and 
even epilepsy and paranoia). Dunin ' was the first to show 
that in reality quite the reverse is true, namely, that con- 
stipation is the result of many nervous conditions and not 
their origin, for a treatment directed against the existing 
neurosis in many instances removes the constipation with- 
out the administration of cathartics. Dunin, however, 
goes too far in ascribing all cases of habitual constipation 
to a neurosis. There are certainly cases of chronic consti- 
pation in which no nervous derangement whatever can be 
discovered. 

Formerly the cause of constipation was presumed to lie 
in abnormal conditions of the bowels. Thus, peritonitic 
adhesions of the intestines and congenital malposition of 
the bowel have been held responsible for chronic consti- 

1 Dunin : " Ueber habituelle Stuhlverstopf ung, deren Ursachen und 
Behandlung. " Berliner Klinik, 1891, Heft 34. 



CONSTIPATION. 301 

pation. But aside from the fact that these two factors 
are so rarely found in comparison with the large num- 
ber of cases of constipation, Leichtenstern ' proved that 
an abnormal position of the bowels need not cause con- 
stipation as long as the intestinal lumen is not obstructed. 

Spasmodic contraction of the bowels or enterospasmus 
is produced by increased peristaltic action confined to one 
portion of the bowels. A permanent contraction of a por- 
tion of the intestine exists which may affect both the circu- 
latory and the longitudinal muscles. This spastic state 
may be of variable duration and may involve intestinal 
segments of different lengths. The contracted portion of 
the bowel is almost completely occluded, thus creating 
an obstacle to the onward passage of the intestinal con- 
tents. 

The enterospasm may involve the entire small intes- 
tine. The abdomen then appears contracted in the form 
of a trough. This condition is met with in spinal menin- 
gitis and in other morbid processes involving the pons 
and the medulla oblongata. Moreover, the same affection 
occurs in chronic lead poisoning. 

Much more frequent than the diffused enterospasm is 
the localized or circumscribed contraction of the bowel 
which usually affects a certain portion of the large intes- 
tine. Here the abdomen does not show any abnormal 
appearance on inspection. This condition is frequently 
met with in nervous people, neurasthenics, hysterical per- 
sons, and also in those debilitated by long ailments. Con- 
stipation of an obstinate nature, lasting for several days, 
followed by a painful evacuation of small balls (like the 

1 Leichtenstern : " Verengerungen, Yerscbliessungen und Lageveran- 
derungen des Darms." von Ziemssen's "Handbuch der speciellen Pa- 
thologie und Therapie, " Bd. vii., 2te Halfte, Leipzig, 1878. 



302 DISEASES OF THE INTESTINES. 

faeces of goats) or leadpencil-shaped fecal matter are the 
predominant symptoms. Pains in the umbilical region or 
on the left side of the lower abdomen of a constricting 
nature and relieved after a very small passage, are also 
characteristic of this affection. 

Constipation Depending upon Diseases of Other Organs. 
Numerous diseases of the stomach give rise to constipa- 
tion. Foremost among these are hyperchlorhydria, ulcer 
and cancer of the stomach, ischochymia, atonic and catar- 
rhal conditions of the stomach, and finally achylia gastrica 
— the last three, however, show a smaller percentage of 
this complication. In this group of cases constipation is 
attributable either to the abnormal qualities of the chyme 
passing through the digestive canal or to the retarded gas- 
tric prochoresis or to some retarding reflex act originating 
in the stomach. 

Tumors of the intestinal canal or of neighboring organs 
compressing the bowel, strictures within the intestines, and 
peritonitic adhesions are also often associated with consti- 
pation. These conditions, moreover, frequently lead to a 
far more serious condition, namely, to acute or chronic 
ileus. Catarrhal inflammation of the small intestine alone 
is also ordinarily accompanied by constipation. Ulcers 
of the small intestine are sometimes attended by constipa- 
tion. Ulcers of the large bowel are ordinarily accompa- 
nied by diarrhoea, excepting dysenteric ulcers, which often 
produce constipation. Fissure of the anus and an increased 
contraction of the sphincter of the anus are often causes of 
constipation. 

In many diseases of the brain, spinal cord, and the 
nerves (cerebro-spinal meningitis, brain tumors, hemor- 
rhages of the brain, chronic hydrocephalus, myelitis, 
tabes, neuroses and psychoses) constipation is present. 



CONSTIPATION. 303 

It is due here either to a disturbance of the nervous appa- 
ratus communicating with the centre for defecation, or to 
a diminished sensibility of the intestinal nerves so that 
stronger stimuli are required than under normal condi- 
tions. 

Diseases of the lungs, heart, liver, and kidney increase 
the liability to constipation, first, by the hyperemia of 
the intestinal mucosa, and, secondly, by the congestion 
in the portal circulation, which both retard the peristalsis- 
Diabetes mellitus often gives rise to constipation, first, 
by the polyuria which drains the organism of water and 
thus leads to an exsiccated condition of the fecal matter, 
and, secondly, by the diet, which consists principally of 
meat and of a very restricted quantity of starchy food. 
Diarrhoea, however, is not rarely met with in this disease. 

Amemia and chlorosis are also often attended by consti- 
pation. The latter is due to an atonic condition of the 
bowels, which is one of the symptoms of the general mus- 
cular atony dependent upon the impoverishment of the 
blood. 

Most febrile diseases are also usually accompanied by 
constipation. Lack of exercise and an increased elimina- 
tion of the fluids of the body caused by the greater activity 
of the lungs and the sudoriparous apparatus are the prin- 
cipal factors. Constipation encountered in people living 
in high altitudes must be ascribed, according to Euedi, 1 
to the same causes. The restricted diet, consisting chiefly 
of milk, also contributes to a lessened activity of the intes- 
tinal peristalsis. 

Symptomatology. — In many cases constipation does not 
induce any subjective symptoms whatever. Ordinarily, 

1 Carl Ruedi : " On Indications and Contraindications of High Alti- 
tude in Phthisis. " The Climatologist, July, 1892. 



304 DISEASES OF THE INTESTINES, 

however, continued constipation gives rise to sensations 
of slight pressure, fulness and tension in the abdomen; 
and borborygrai may at times molest the patient. Occa- 
sionally intense colicky pains are experienced. These are 
due to an increased effort of the intestines to rid them- 
selves of the accumulated fecal matter by violent contrac- 
tions. The abdomen is often symmetrically distended, 
rarely asymmetrically, namely, in partial atony of the 
bowels. 

In patients with thin abdominal walls, a more or less 
filled state of some portions of the intestine, especially 
of the colon, may be perceived by inspection and pal- 
pation. The appetite is often diminished and in some 
instances complete anorexia exists. Other gastric symp- 
toms — belching, nausea, pyrosis, feeling of pressure after 
meals, and bad taste in the mouth — may be present. That 
all these symptoms are due to the constipation and not to 
a separate lesion in the stomach, is proven by the fact that 
they all disappear as soon as efficient evacuation of the 
bowels has taken place. 

Besides these gastric symptoms the following derange- 
ments may be present : congestion of the head, dizziness, 
headaches, sleeplessness, a despondent feeling, palpitation 
of the heart, tachycardia, irregularity of the pulse. The 
latter symptoms have been considered by many writers to 
be due to auto-intoxication from the intestinal tract. Ac- 
cording to the experiments of Bouchard, 1 however, this 
does not seem to be true, for this investigator has shown 
that intoxication within the intestinal tract takes place 
when there is a retention of fluid fecal matter, but not 
when the faeces are solid, for in this condition no absorp- 
tion of the fecal matter takes place. 

1 Bouchard : Loc. cit 



CONSTIPATION. 305 

Constipation which has lasted for a long time, as a rule, 
terminates by a spontaneous evacuation of ordinarily very 
hard masses of fecal matter. The latter often appears in 
the form of balls which may be covered with a thin layer 
of mucus. In some instances the constipation terminates 
in an attack of diarrhoea. In these cases the diarrhoea has 
been caused by an acute hypersemia and inflammation of 
the intestinal mucosa due to the hardened fecal matter, the 
latter becoming liquefied through increased intestinal per- 
istalsis and secretion. In other instances no spontaneous 
evacuation takes place and it becomes necessary to make 
use of different cathartic remedies in order to produce a 
movement of the bowels. 

Retention of fecal matter may cause not only a slight 
transient catarrhal condition of the bowels as just referred 
to, but may, although rarely, effect more pronounced an- 
atomical lesions, as formation of ulcers (stercoral ulcers), 
local peritonitis, and even perforation of the gut with fatal 
issue. 

One of the serious symptoms which may result from 
continued constipation is fecal colic. The latter begins 
with sudden violent pain of a colicky nature in the ab- 
domen. In weakened persons fainting spells may occur. 
The abdomen is usually greatly bloated and tender on 
pressure. Passing of wind (flatus) gives temporary relief, 
but the pains soon reappear and subside onl}' after an 
efficient evacuation. Fecal colic is mostly observed in 
cases of obstinate constipation, although it may occur in 
patients with daily evacuations of the bowels, but in these 
insufficient fecal passages must be presupposed. In fact, 
hardened balls of fecal matter can be discovered in such 
cases on palpation of the abdomen. 

These conditions are not alwavs of a mild character. 
20 



306 DISEASES OF THE INTESTINES. 

As a rule cathartic remedies are efficient. In some cases, 
however, the latter produce energetic intestinal peristalsis 
and violent pains, but fail to secure a copious movement. 
Under these circumstances the patient may after a while 
sink into a state of collapse and be seized with a paroxysm 
of vomiting. The clinical picture now resembles very 
closely that of ileus. High rectal irrigations or injections 
of oil into the bowel ordinarily yet produce the desired 
effect and the patient quickly recuperates. In rare cases, 
however, especially in very old and cachectic persons, these 
means also remain fruitless. Total paralysis of the intes- 
tine now takes place and the patients are then in a most 
critical condition. 

A frequent complication of constipation is the formation 
of fecal tumors. They are found most frequently in the 
caecum, rectum, and at the colic flexures. These masses 
may cause a dislocation of the colon ; thus, such a tumor 
may be felt just above the symphysis and may belong to 
the transverse colon which has been dragged down to that 
region. Fecal tumors are as a rule easily recognizable. 
They are not of a very firm consistency, have a rosary-like 
configuration, are movable, and undergo a change in shape 
upon pressure. They may be of large size. Thus Levi * 
found the rectal pouch of a patient suffering for nine years 
with constipation filled with a fecal mass weighing four 
pounds. Still larger fecal concretions have been found 
by Lemazurier. 2 These large masses necessarily dilate 
the colon. 

Habershon described cases in which the dilated colon 
measured twelve to fifteen inches in circumference, and 
stated that some of the normal sacculations of the colon 

1 Levi : Gazette med., 1839. 

2 Lemazurier : Arch. gen. denied., vol. i. 



CONSTIPATION. 307 

may become distended to such a degree that they appear 
as true diverticula. In the latter fecal accumulations may 
occur which remain undisturbed by the further passage of 
the intestinal contents. These stagnant fecal masses often 
produce inflammatory processes which may lead to a de- 
struction of the intestinal coats down to the peritoneum. 
The colon occasionally is distended not only in width 
but also in length. The latter circumstance explains the 
abnormal position of the bowel often present in these 
cases. 

Among the local symptoms which constipation produces 
hemorrhoids play an important part. They are treated 
in a special chapter. 

A host of nervous symptoms may develop in consequence 
of constipation in people who are apparently not nervously 
inclined. Thus constipation lasting several days may 
produce slight cerebral symptoms, namely, a sensation of 
pressure, weight and dulness in the head, sometimes 
headaches and vertigo. The dependence of these symp- 
toms upon constipation is proved by the fact that after a 
full evacuation of the bowels they all suddenly disappear, 
but again return after another period of constipation. We 
have as yet no positive explanation of the causation of 
these symptoms. Some authors assume them to be of a 
reflex origin. 

Leube * described several cases of intestinal vertigo in 
which the dizziness was due to pressure existing in the lower 
end of the bowels, the vertigo appearing only in consequence 
of irritation of the intestinal walls by fecal matter or a large 
amount of gas, or by the examining finger. Leube concluded 
that pressure upon the hemorrhoidal plexuses of the sym- 

1 Leube : "Ueber Darmschwindel. " Deutsches Arch. f. klin. Medi- 
cin, Bd. 36, 1885. 



308 DISEASES OF THE INTESTINES. 

pathetic nerve produces the sensation of vertigo in are- 
flex way. 

Senator 1 tried to explain the above symptoms as due 
to the absorption of poisonous gases within the intestine, 
such as sulphuretted hydrogen, and Nothnagel assumed 
that ptomains may be absorbed and thus cause an auto- 
intoxication. But neither theory seems to hold good; for 
sulphuretted hydrogen gas exists in too small quantities 
to produce any marked symptoms, and the fecal ptomains 
can scarcely be absorbed from dried- up fecal matter. 

As mentioned above, real brain diseases, hypochondria 
and melancholia, are never due to constipation as such. 
There is, however, hardly any doubt that in nervously 
inclined individuals obstinate constipation may be a con- 
tributing factor in the further development of some psy- 
choses, especially melancholia. 

Fecal fever, which has played a great part in the works 
of old writers, appears to be due in most instances not to 
an accumulation of fecal matter but rather to some com- 
plicating condition, an inflammatory process, a stercoral 
ulcer, a local peritonitis, etc. In infants and children, 
however, who much more readily develop fever, the latter 
may be due to accumulation of fecal matter alone. Some 
of the English writers have referred to chlorosis as due to 
habitual constipation, and Clark has treated chlorosis with 
cathartics. But this view has not been generally accepted 
and the dependence of chlorosis upon constipation is far 
from being proved. 

Diagnosis. — The recognition of constipation is not diffi- 
cult, except in those cases in which there is a daily evacu- 
ation of the bowels but not a complete one, so that fecal 

1 Senator: "Hydrothionsemie und Selbstinfection durch abnorme 
Verdauungsvorgange. " Berl. klin. WocheDschr., 1868, No. 24. 



CONSTIPATION. 309 

matter is more and more accumulated in the intestine. 
Frequently hard fecal masses of rosary shape will be dis- 
covered on palpation of the abdomen in the region of the 
colon. Most often the sigmoid flexure and the caput coli 
are the favored sites of this phenomenon. The detection 
of these fecal masses shows the existence of an insufficient 
evacuation of stools, in other words, constipation. 

The diagnosis of pure constipation (habitual constipa- 
tion) can be made, if organic lesions of the bowels (stric- 
ture, tumor, and also intestinal catarrh) can be excluded. 
This diagnosis having been made, it is of importance to 
find out to which group the constipation belongs, whether 
it be due to an abnormal gastric condition, or disease of 
some other organ, or to a neurotic affection of the bowel 
itself (atonic and spastic constipation). 

Constipation due to anomalies of the function of the 
stomach can be ascertained only after a thorough analysis 
of the gastric contents and after resort to treatment directed 
toward the improvement of the gastric condition. Con- 
stipation due to disease of other organs (heart, lungs, 
kidneys, liver, etc.) may be assumed to exist when an 
examination discloses their presence. Constipation due 
to atony of the bowels is often revealed by a slightly 
bloated condition of the abdomen with evacuations of hard 
fecal matter, often balls, sometimes covered with a thin 
layer of mucus. While there may be a feeling of despond- 
ency, dizziness, and somnolence, real severe pains are 
rare. Constipation due to a spasmodic contraction of the 
bowel is attended with a general feeling of uneasiness and 
pains in the abdomen, occasionally accompanied by fainting 
fits. The fecal matter is not so hard, although it is evac- 
uated only after severe straining of the abdominal walls, 
and is voided in narrow tapelike pieces. The abdomen 



310 DISEASES OF THE INTESTINES. 

is often rather sunken and contracted. Intestinal coils can 
frequently be palpated. 

Prognosis. — The prognosis of constipation is favorable in 
the large majority of cases, especially with regard to life. 
It must, however, be admitted that after having lasted a 
long time constipation may give rise to severe, sometimes 
irreparable anatomical lesions of the intestine, as for in- 
stance atrophy, peritonitic adhesions, malpositions of the 
bowel, even perforation with consequent peritonitis and 
death. The latter instances, however, are very rare, if we 
take into consideration the large number of persons suffer- 
ing with constipation who reach an advanced age, and they 
will most probably become still less frequent if the patients 
do not neglect this condition and consult a physician at an 
early period. 

Treatment. — Cases of constipation due to dyspeptic con- 
ditions must be treated by first ameliorating the gastric 
disorder. Cases of constipation secondary to diseases of 
other organs must be managed by first applying remedies 
toward the improvement of the original trouble. If these 
alone are insufficient, they must be managed like typical 
cases of habitual constipation. 

With regard to the prophylaxis of constipation, we 
should avoid administering cathartics in slight transient 
disturbances of digestion and rather let nature take its own 
course. Never put a patient on a one-sided diet for too 
long a time ; the exclusion of vegetables, fruits, and starchy 
foods in general, from the diet is frequently the cause of 
marked constipation. A hygienic mode of living, regular 
habits, less business strain and worr3 r , and more outdoor 
life and exercise are of the greatest importance in the pre- 
vention of constipation. 

Generally no purgatives whatever, or as few as possible, 



CONSTIPATION. 311 

should be used. The chief measures in curing constipa- 
tion are the following : 

1. The Jloral Treatment. — It is of utmost importance to 
allay the patient's anxiety to have a movement. He should 
be told to pay as little attention as possible to the condi- 
tion of his bowels. Absence of a movement for a few days 
will cause no harm whatever. Avoidance of purgatives and 
keeping the mind of the patient free from worry over the 
condition of his bowels is occasionally sufficient to produce 
spontaneous movements. 

Training the patient to have an evacuation at a certain 
time every day is also of great importance. The patient 
should be taught to go to the watercloset every morning at 
the same time and should try to have a passage. In doing 
this he should not exert himself too hard and should spend 
only three to five minutes for this purpose. In case the 
attempt be unsuccessful, he should wait until the follow- 
ing moruing, unless there is a strong desire to go to stool. 
Trousseau was the first to advocate this mode of treatment,, 
and the importance of this maxim has since been gen- 
erally accepted. My own experience coincides with that of 
others, and I cannot lay too much stress upon this ap- 
parently unimportant piece of advice. Even when using 
other measures in combating constipation we must not 
lose sight of the influence in " training " the patient. 

2. Dietetic Measures.— The dietetic measures have for 
their object the ingestion of foods which increase the intes- 
tinal peristalsis and the avoidance of substances which are 
of a more or less constipating nature. Advocate the drink- 
ing of plain cold water, especially in the fasting condition, 
the use of buttermilk, cider, grapes, oranges, and other 
fruits, raw or cooked (apples, prunes, pears, peaches), 
lemonade, honey; salmon, sardines, herring, plenty of 



312 DISEASES OF THE INTESTINES. 

vegetables, spinach, green peas, cauliflower, cabbage, green 
salads, rye bread, butter. Avoid strong tea, claret, huckle- 
berries, cacao and chocolate. 

Some substances have a constipating effect upon one 
person and a purgative effect upon another, as for instance 
milk. In treating the patient we must acquaint ourselves 
with his peculiarities in this respect. In prescribing a 
diet for patients with constipation we should allow them 
the usual foods with a predominance of those just enum- 
erated. It is needless to say that some of the articles 
mentioned will not be permissible in every case. Thus a 
patient with a very delicate stomach should certainly be 
told not to take cabbage and cider, etc. 

In some instances in which too much vegetable food has 
been taken and a constipation has developed in consequence 
of the intestine being overburdened with too much ballast, 
food articles containing much cellulose will have to be re- 
stricted. As a rule, however, a mixed diet with a prepon- 
derance of vegetable food is adapted for most cases. 

3. Mechanical Measures. — The mechanical measures 
serve to strengthen the bowel and in this way promote a 
better action, or they directly effect a stronger intestinal 
peristalsis. The mechanical measures comprise massage, 
exercise, electricity, hydrotherapy, and lastly injections 
into the bowel. 

(a) Massage. The general principles of massage have 
been described above (page 80). Its action consists prin- 
cipally in producing more efficient peristalsis of the large 
bowel. It should therefore never be used in conditions in 
which spasmodic contractions of the bowel may be assumed 
to exist. Its most useful field lies in cases of atony of the 
bowel. 

Massage should be applied at first either by the physi- 



CONSTIPATION. 313 

cian himself or under his strict supervision. It should 
never be applied with much force and it should never 
cause pain. According to Illoway, ' the duration of massage 
treatment should be from five to fifteen minutes for a 
grown person and from three to five minutes for children. 
The massage should be employed every other day with 
great regularity for a period of about six weeks at least. 
Illoway suggests that the massage sittings may be per- 
formed less frequently as soon as there is a decided 
improvement in the condition of the bowels. It is, how- 
ever, never advisable to stop the massage treatment sud- 
denly, but it should rather be kept up for a long period 
of time, although later at longer intervals. Massage is 
best applied early in the morning in the fasting condition 
of the patient. During its employment no other remedy for 
constipation should be administered unless the latter has 
lasted several days and gives rise to various symptoms. 

Auto-massage may also be of benefit. This may be 
carried out by the patient himself, kneading his abdo- 
men principally over the course of the large bowel with 
his right hand or by means of some instrument adapted 
for this purpose. Sahli was the first to recommend the 
use of a cannon-ball, weighing about three to five pounds. 
These balls may be wrapped in flannel and rolled over the 
abdomen for about five to ten minutes. This procedure is 
best performed early in the morning in bed in the fasting 
coDdition of the patient. The ball is best rolled over the 
abdomen in a spiral direction, principally along the course 
of the colon. But the other parts of the abdomen should 
also be subjected to this procedure. The flannel covering 
the ball may be left off if desired. Dr. A. Eose, 2 of New 

1 Illoway : "Constipation in Adults and Children, " New York, 1897. 

2 A. Rose : New Yorker medizinische Monatsschrift, January, 1893. 



314 DISEASES OF THE INTESTINES. 

York, has practised this method quite extensively and 
warmly recommends its use. Dr. Arthur Kahn, 1 also of 
New York, has invented an apparatus for auto-massage 
which may also be used for this purpose. Rosenheim 2 
suggests using auto-massage in the following manner : The 
patient in an upright posture makes short palpating strokes 
with the fingers of his right hand inclined somewhat in- 
wardly over his abdomen for several minutes. In this 
procedure also the course of the colon is especially to be 
considered. 

(b) Gymnastic exercises. Exercises which bring into 
play especially the muscles of the abdomen are of great 
benefit. Exercises on the horizontal bar, horseback rid- 
ing, mountain climbing, skating, rowing, bicycle riding, 
are all beneficial, provided these sports are not kept up 
for too long a time, and do not cause a superabundant 
loss of water by extensive perspiration. 

Indoor gymnastic exercises may also be used. Bend- 
ing of the body, rotations of the trunk, especially in a, 
siting posture, quickly drawing up the knees toward the 
thorax in the recumbent position, also alternate squatting: 
and rising are of special benefit. The passive, so-called 
Swedish movements may also be employed either in a 
Zander Institute or manually by a nurse. Massage and 
these exercises are best applied in conjunction. 

(c) Electricity. Percutaneous electrization (principally 
faradization) of the abdomen has been recommended by 
some writers as a cure for constipation. Recently direct 
electrization of the intestine, applying one electrode to the 
rectum and the other over the abdominal wall, has been 

1 A. Kahn : Centralblatt fur Chirurgie imd orthopadische Mechanik, 
Berlin, 1889, Bd. v., p. 4. 

2 Th. Rosenheim : "Krankheiten des Darms, " 1893, p. 513. 



CONSTIPATION. 315 

used. Boudet's rectal electrode is best adapted for this 
purpose, especially when galvanization is employed. The 
insertion of one electrode in the stomach and the other in 
the rectum, as suggested by Kussmaul and Leubuscher, 1 
has not come into use to any extent. 

Electricity seems to act favorably on the intestinal peri- 
stalsis and it is especially indicated in the treatment of 
constipation in conjunction with massage, particularly in 
atony of the bowel. Doumer 2 has very recently recom- 
mended the use of static electricity. He applies localized 
franklinization in the form of sparks or "souffles elec- 
triques " for about five to twelve minutes in the iliac fossae, 
principally the left. By the employment of this method 
of treatment every other day for a period of two to three 
weeks Doumer reports having cured the most obstinate 
cases of chronic constipation. 

(d) Hydr other apeutic means. Hydrotherapeutic meas- 
ures may be applied either alone or in conjunction with 
the above-named mechanical means. Hackel 3 gives the 
following rules : In constipation due to atony of the bowels 
use a jet of water of about the thickness of the small finger 
with the force of two atmospheres, first over the epigas- 
trium. The hose of the mobile douche is then placed over 
the region of the colon. Charcot's douche is best adapted 
for this purpose, as it allows a sudden change of tempera- 
ture. When using the latter apparatus the temperature 
can be readily changed to any degree desired during its 
application. The alternations in temperature should be 
considerable, often from 102° F. to 120° F. Thus both 
mechanical and thermic effects come into play. After 

1 Leubuscher : Centralbl. f. klin. Medicin, 1887, No. 25. 

2 E. Doumer et Musin : Annales d'Eleetro-Biologie, 1898, p. 722. 

3 Jeannot Hackel : Deutsche nied. Wochenschrift, Jan. 5, 1899. 



316 DISEASES OF THE INTESTINES. 

using the douche over the abdomen, it is applied over the 
chest and back, throwing a fan-shaped jet, the temperature 
being kept constant. 

In constipation due to spastic contractions of the bowels 
Hackel applies water under a pressure of two and a half 
kilograms, letting it flow in the form of a fine spray. It 
falls like a fine rain on the abdomen. The temperature of 
the water should not be lower than 95° F. and not higher 
than 102° F. and should not be changed. The duration of 
the douche is from two to two and a half minutes. The hose 
is directed along the course of the colon while the water 
constantly runs over the epigastrium. Ninety-six such 
circuits over the intestines may be made. Afterward the 
lower extremities, chest and back, are douched. The skin 
of the abdomen must not be subjected to vigorous friction 
after the douche ; the extremities, however, should be well 
rubbed. After the douche the patient should lie in bed 
for about five to ten minutes, being warmly covered, and 
then may walk for about a quarter of an hour. 

Cold sitz baths (12° C.) for about five minutes are also of 
benefit, as well as a Priessnitz compress or Neptune's gir- 
dle over the abdomen over night. 

4. Injections. — Injections into the bowels of water alone 
or of water with the addition of soap, vinegar, common 
table salt, or castor-oil are often used with advantage. 
The amount of fluid required for a purging effect varies in 
different persons. As a rule a pint to a quart or one and 
a half quarts are necessary. These water injections should 
be made daily at the same hour for a period of three to 
four weeks, aod then every other day also for the same 
length of time. 

Recently Klemperer ' has recommended the use of small 
1 Klemperer : " Therapie der Gegenwart, " 1899, p. 48. 



CONSTIPATION. 317 

water injections into the bowel at bed-time. Half a 
pint of water is injected and the patient is told to re- 
tain the fluid. The latter is very soon absorbed by the 
intestine and the patient has an evacuation on the fol- 
lowing morning. Klemperer cured cases of constipation 
by giving these small water injections for about three 
weeks every day, and then every other day for the follow- 
ing two or three weeks. 

Injections of sweet oil into the rectum, which have been 
recommended by Kussmaul and Fleiner, are best adapted 
for the treatment of obstinate cases of constipation, espe- 
cially if due to spasmodic contraction of the bowel. The 
injections should be made in the following way : Take 
about one pint of good olive oil and heat it to the tem- 
perature of the body. Then take a fountain syringe pro- 
vided with a soft-rubber rectal tube, and inject the oil into 
the rectum. The patient takes the injection while in bed, 
and it is advisable to have him retain the oil as long as 
he can. I usually order it to be taken in the evening, so 
that the patient may fall asleep at once and retain it over 
night. The following day the oil is passed and an evacua- 
tion follows. If the patient is treated for two to three 
weeks with oil, the spasmodic condition will subside. The 
oil injections should then be given every other night for 
a period of two weeks, thereafter twice a week for some 
time, then once a week for several months. 

Injections of glycerin, which were first recommended 
by Anacker, 1 are also beneficial. Two to four grams of 
glycerin are dissolved in about three to four ounces of 
water and injected into the rectum. An evacuation of 
the bowels results in a very short time, ten to twenty 

1 Anacker : " DasPurgativ Oidtraann. " Deutsche med. Wochenschr. , . 
1887, p. 823. 



318 DISEASES OF THE INTESTINES. 

minutes. The glycerin may also be given in the form 
of a suppository, acting the same way. While this mode 
of treatment is very convenient to produce an evacuation 
of the bowels, it should not be resorted to daily, as the 
bowel is thereby greatly irritated. 

Similar in its action but less harmful is Flatau's ] method 
of applying boric acid directly to the rectum. Boric-acid 
powder, about one to three grams, may be inserted into 
the rectum with the finger or blown into it by means of a 
powder-blower through the anus. A movement of the bow- 
els occurs half an hour to three hours later. 

5. Purging Medicaments. — In many instances of habitual 
constipation the use of drugs must be resorted to. As a 
general rule we should administer as mild cathartic rem- 
edies as possible, and instead of increasing the dose we 
should rather try to reduce it gradually, and ultimately 
relieve the constipation without the help of cathar- 
tics. 

The various preparations of rhubarb are very serviceable. 
Yinum rhei and tinctura rhei aromatica or dulcis may be 
given in doses of from half a teaspoon to one teaspoonful. 
Rhubarb may also be given as a powder in conjunction 
with calcined magnesia and bicarbonate of soda, as for in- 
stance : 

1^ Pulv. rad. rhei, 

Magnes. ustas, 

Sod. bicarb aa 20.0 (3 v.) 

M. f. pulv. D. ad scatulam. S. One-half teaspoonful two or three 
times a day. 

Pulvis glycyrrhizse compositus is also a very suitable prep- 
aration. It can be given in teaspoonful doses at night or 
in the morning. It has the following composition : 
1 Flatau: Berl. klin. Wochenschr., 1891, p. 231. 



CONSTIPATION. 319 

I£ Fol. sennas, 

Ead. glycyrrhizse aa 10.0 ( 3 iiss.) 

Fruct. foeniculi, 

Sulph. depur aa 5.0 ( 3 ii) 

Sacch. alb 30.0 ( I i.) 

Aloes is another very efficient and popular remedy. It 
effects a movement of the bowels in about eight to twelve 
hours after its ingestion and does not cause any griping. 
I often give the following prescription : 

I^ Aloes 1.0 (gr. xv.) 

Extr. belladonna?, 

Extr. strychn aa 0.3 (gr. v. ) 

Extr. et pul v. glycyrrhizse q. s. 

Ut f. pil. No. xx. S. One pill twice daily. 

Of the newer remedies podophyllin and cascara sagrada 
are very valuable. Podophyllin is given in doses of one- 
sixth to one-third of a grain twice a day. I use the fol- 
lowing prescription : 

$ Podophyllin 0.3 (gr. v. ) 

Extr. physostigmatis, 

Extr. nuc. vomic aa 0.5 (gr. viiss.) 

M. f. cum extr. et pulv. glycyrrhizse q. s. pil. No. xxx. S. One pill 
twice daily. 

Oascara sagrada may be given in the form of fluid extract, 
fifteen to twenty-five drops twice daily, or cascara sagrada 
with maltine, one teaspoonful once or twice daily. 

Syrup of figs, one teaspoonful at night time, or tama- 
rind, also one teaspoonful, is often of value. 

Jalap and colocynth belong to the stronger drastic rem- 
edies, and hardly ever find a place in the treatment of the 
cases under consideration. Hunyadi Janos water, Fried- 
richshaller, Homburger or Eakoczy waters, Apenta, Eu- 
binat and the like are also sometimes of benefit. They 
should, however, not be used for a long period of time in 
cases of anaemia and neurasthenia. 



CHAPTER XL 

NEKVOUS AFFECTIONS OF THE INTESTINES. 

MOTOR NEUROSES. - ( Continued. ) 
Paralysis of the Intestines. 

Partial paralysis of the intestines may occur and give 
rise to symptoms resembling a complete occlusion of the 
intestinal lumen. Paralysis arising in consequence of a 
mechanical obstacle to the passage of the intestinal con- 
tents has been described above. Here we shall deal with 
primary paralysis of the intestine without any organic ob- 
stacle. In this condition the peristaltic motion of this 
organ is absent. The passage of fecal matter is thereby 
interrupted and symptoms of obstruction result. 

Henrot ' distinguishes three forms of intestinal paraly- 
sis: 

1. Direct paralysis of a portion of the intestine caused 
by alterations of its walls. Thus an intestinal coil may 
become paralyzed after repeated forced reposition of a 
hernia or after it has been incarcerated in the hernial 
pouch for a long time. The paralysis may also occur as a 
consequence of a direct trauma or after extensive abdomi- 
nal operations, and finally after various chronic inflamma- 
tory and ulcerative processes of the intestine (enteritis, 
tuberculosis, dysentery). 

2. The paralysis is caused indirectly in consequence of 

1 Henrot : " Des Pseudo-etranglements, " Paris, 1865. 



INTESTINAL PARALYSIS. 321 

a reflex nervous action. Thus contusion of the testicles, 
inflammation of a hydrocele, abscesses of the abdomen may 
inhibit the abdominal nerve centre in such a way that the 
peristalsis ceases, although this is of very rare occurrence. 

3. The intestinal paralysis may result from general neu- 
roses (hysteria), from psychoses (melancholia, hypochon- 
dria), or from affections of the central nervous system 
(meningitis, brain tumors, tabes dorsalis, myelitis, etc.). 

Besides these three groups, which are all of a more or 
less acute character, Kosenheim also mentions paralysis of 
the intestines as a consequence of coprostasis due to atony 
of this organ, which condition is less acute and more pro- 
tracted. The patient, as a rule, has suffered from consti- 
pation for a long time. Evacuation of the bowels has been 
artificially produced only after the apx>earance of many 
annoying symptoms. At last the usual remedies refuse to 
work and the patient now becomes a chronic sufferer. 
Dyspepsia, intense meteorism, and palpitations of the 
heart are present. The ingestion of food grows smaller 
every day and the patient becomes weaker. This condition 
may last for weeks and months, and if no radical remedies 
are resorted to, the patient may ultimately be seized with 
fecal vomiting and die of the intestinal paralysis. 

According to Rosenheim, a sudden attack of serious in- 
testinal obstruction in a patient suffering from chronic 
constipation is, as a rule, not caused by paralysis of the 
intestine, but rather by an occlusion of the intestinal lu- 
men through hardened fecal matter. 

The diagnosis of intestinal paralysis can be made if all 

the other numerous factors causing ileus can be excluded 

and one of the above-mentioned etiological points can be 

discovered. 

The treatment of these cases consists in the applica- 
21 



322 DISEASES OF THE INTESTINES. 

tion of electricity (recto-abdominal galvanization), mas- 
sage, and purgative high rectal injections. Cases in 
which the paralysis is caused by chronic constipation must 
be treated by high injections of either ice water two hun- 
dred to five hundred grams, or water with the addition of 
two hundred to five hundred grams of oil. These injec- 
tions should be applied twice or three times a day for sev- 
eral days in succession until a satisfactory result has been 
obtained. Massage and electricity can be used in addition 
to these injections. Internal purgatives, even croton oil, 
are not efficacious in this class of cases. The use of mer- 
cury, however, in doses of three hundred to eight hundred 
grams is here of great value. In cases in which the lower 
part of the colon is the seat of the paralysis, the stagnant 
fecal matter must be removed with the hand before the 
rectal injection is resorted to. 

Proctospasmns, or Spasm of the Rectum. 

This condition consists in attacks of painful contraction 
of the sphincters of the rectum and is in most instances 
a secondary affection. It is mostly found in inflammatory 
and ulcerative processes of the rectum and colon, in fissure 
of the anus, and also in inflammatory diseases of neighbor- 
ing organs, bladder, prostate, uterus. 

Spasm of the rectum may, however, occur also indepen- 
dently as a primary nervous affection. As such it is prin- 
cipally met with in individuals with a nervous taint, and 
in diseases of the spinal cord. The attacks of proctospas- 
mus differ in intensity and also in duration. Sometimes 
they last only a short while, a few minutes, sometimes sev- 
eral hours or even days. In the milder form defecation is 
accompanied by intense pains and takes place only after 
great effort. In the severer forms there is a strong desire 



PARALYSIS OF THE SPHINCTERS. 323 

for defecation, but notwithstanding the most intense pains 
and great straining there is no movement of the bowels. 
If these attacks last several hours they greatly weaken the 
patient and render him very despondent. The anus is very 
sensitive to touch, and a digital examination of the rectum 
during the spasm is hardly ever possible. X thorough 
examination of the rectum can be made only during anaes- 
thesia. In instances of very severe proctospasinus a tran- 
sient paresis or paralysis of the sphincter muscles may 
result. 

The diagnosis of proctospasmus is easy, as the symp- 
toms are very distinct. The diagnosis of the primary ner- 
vous form will be made if organic diseases of the rectum 
and of the neighboring organs can be excluded. 

The treatment must be directed principally toward the 
primary affection. In cases of nervous proctospasinus the 
treatment should be symptomatic and consist in the use 
of narcotic remedies. In severe forms of this malady hy- 
X^odermic injections of morphine must be resorted to. In 
some instances a forcible divulsion of the sphincter under 
chloroform narcosis may become necessary. 

Paresis and Paralysis of the Sphincters of the Anus. 

Paralysis of the anal sphincters occurs frequently in con- 
sequence of long-lasting affections of the rectum. Some- 
times over-exertion of these muscles (tenesmus) ultimately 
leads to exhaustion. Occasionally ulcerations and infiltra- 
tions of the rectum involve also the sphincters or entirely 
destroy them, thus annulling their functions. The tonicity 
of the sphincter muscles may be impaired in persons who 
have suffered for a long time from an accumulation of 
fecal matter in the lower portions of the bowel. The mus- 
cular apparatus being over-irritated for a long time becomes 



324 DISEASES OF THE INTESTINES. 

weakened and exhausted. Diseases of the brain and spi- 
nal cord, leading to inhibition of the will power, may like- 
wise cause paralysis of the sphincters. 

Atony, paresis, and paralysis form different degrees 
of this affection. Some patients are not able to keep the 
rectum tightly closed, and a small amount of secretion con- 
tinually penetrates through the anus. After defecation 
they have the sensation of not having finished the act. 
Sometimes there may be an involuntary movement of the 
bowels in consequence of the loss of the contractile power. 
This, however, occurs only after strong excitement, intense 
bodily exertion, during urination, and rarely in walking. 

In case the paralysis of the sphincters is complete, flatus 
and fecal matter will escape involuntarily even in a state of 
rest. In paralysis resulting from proctitis, hemorrhoids, 
stricture, etc., there is a continuous dripping of a muco- 
sanguinary secretion which greatly irritates the skin sur- 
rounding the anus. 

Diagnosis. — Paralysis of the anal sphincter can be recog- 
nized very easily. The anus appears patulous and the 
anal folds have disappeared. Two and even three fingers 
may be introduced into the rectum without encountering 
any resistance. In making the diagnosis of a purely ner- 
vous paralysis anatomical lesions must first be excluded. 
This is clone by means of a thorough examination of the 
rectum with a speculum. 

Prognosis. — Paralysis resulting from anatomical lesions 
of the rectum gives an unfavorable prognosis. In the purely 
neurotic form, however, the prognosis is much better. 

Treatment. — It is of great importance to secure a thor- 
ough evacuation of the bowels, which is best done by rec- 
tal injections of water twice daily. Paralysis due to fecal 
impaction as such, can be entirely remedied by the just 



PERISTALTIC RESTLESSNESS. 325 

mentioned measures alone. Thus Wallace ' reports a cure 
in a case of a nine-year-old boy who was troubled for 
three years with incontinency of fasces, which dropped out 
whenever he walked. The patient was treated with water 
enemas to which castor oil had been added, and later on 
with injections of water with the addition of alum. After 
a month's treatment he entirely recovered. 

In paralysis due to affections of the central nervous sys- 
tem electricity and massage may be of benefit. Hypoder- 
mic injections of strychnine (0.001 to 0.0015 pro dose) 
into the anal folds have been recommended by Eosen- 
heim. Cases in which the paresis of the sphincter is due 
to a difficulty in urination and a continuous straining in 
order to void the bladder, will be improved by artificially 
emptying the bladder by means of a catheter for a con- 
siderable length of time. 

Peristaltic Restlessness of the Intestines. 

Definition. — Increased peristaltic motions of the intes- 
tines in such a way that they become visible through the 
abdominal walls. 

Etiology and Symptomatology. — While in the normal 
state intestinal x)eristalsis is accomplished without being 
visible or making itself felt, in pathological conditions 
increased peristalsis may exist which can be easily per- 
ceived through the abdominal walls and which is usually 
accompanied by distinct noises (borborygmi). Increased 
intestinal peristalsis may accompany any complete or in- 
complete occlusion of the intestinal lumen or it may be 
caused by purely neurotic influences. Here only the lat- 
ter form is dealt with, as the former condition is discussed 
in connection with the organic lesions causing it. 
1 Wallace : St. Barthol. Hosp. Report, 1888. 



326 DISEASES OF THE INTESTINES. 

Usually peristaltic restlessness of the intestines occurs in 
the form of attacks, lasting several hours in succession and 
reappearing after more or less long periods of time. In 
some instances the patients complain of various movements 
and noises within the abdomen due to the increased intes- 
tinal peristalsis, while pain is absent. In other instances 
the above sensations are now and then interspersed with 
severe colicky pains. The majority of cases of peristaltic 
restlessness of the intestines is accompanied rather by con- 
stipation, seldom there are either normal evacuations or 
diarrhoea. In some instances the exaggerated peristaltic 
motions continue even after intestinal digestion has been 
completed, and are accompanied by painful sensations. 
Peristaltic restlessness of the intestines is occasionally as- 
sociated with peristaltic restlessness of the stomach. 

Peristaltic restlessness of the intestines is principally 
met with in nervous persons, in the hysterical and hypo- 
chondriacal. Occasionally, however, it occurs in persons 
who do not present any other nervous symptoms. In 
women this condition may exist during the monthly periods 
or pregnancy. In some persons it appears after the inges- 
tion of highly spiced or indigestible foods, after the exces- 
sive use of tobacco, after great psychical excitement or too 
much brain work. In other cases, however, none of these 
etiological factors can be discovered. 

Diagnosis. — The diagnosis of peristaltic restlessness of 
the intestines is made whenever pronounced intestinal mo- 
tions are visible through the abdomen. The nervous char- 
acter of this condition is recognized, first, after exclusion 
of organic affections of the intestines; secondly, by its pe- 
riodic appearance. 

The prognosis is favorable. 

Treatment. — In the first place it is of importance to in- 



METEORISM. 327 

vigorate the entire organism and especially improve the 
condition of the nervous system. With regard to diet 
sufficient quantities of food should be given, but too spicy 
and indigestible nourishment should be excluded. In 
cases accompanied by some abnormality of the bowels 
their function should be regulated. The bromides, valer- 
ian, and asafetida are of decided value. Drinking of warm 
water or tea and hot applications are useful during the 
attack. Arsenic alone or in combination with iron is of 
benefit in cases combined with anaemia. If the condition 
assumes a violent character and is accompanied by severe 
pains, a small dose of an opiate, alone or in combination 
with belladonna, is appropriate. If the intestinal restless- 
ness appears at night time and prevents the patient from 
sleeping, chloral hydrate, sulphonal, or trional may be ad- 
ministered. Electricity and massage of the abdomen have 
been variously recommended, but neither of the two ap- 
pears to me to be of great value in this condition. Change 
of climate and surroundings is often of benefit. 

Meteorism. 

Meteorism, tympanites, or flatulency signifies a condi- 
tion in which there is an excessive accumulation of gas 
in the intestinal tract. 

If not caused by an organic obstruction in the bowel this 
condition is due to an abnormal state of the intestinal mo- 
tion and absorption. Owing to the first factor we describe 
this anomaly under motor neuroses. 

Etiology. — The causes of the excessive accumulation of 
gas are : 1, an increased ingestion of gases themselves or 
of substances which easily form them ; and 2, a diminu- 
tion or impairment of their elimination from the intes- 
tines. The increased introduction of gases may consist in 



328 DISEASES OF THE INTESTINES. 

swallowing of air or in drinking beverages highly charged 
with carbonic-acid gas. In both instances the gases prin- 
cipally accumulate in the stomach, although a portion of 
them reaches the intestines. 

Increased formation of gas within the intestine is the 
consequence: 1, of various processes of fermentation and 
disintegration of carbohydrates and fats, hydrogen and 
carbon dioxide being the principal gases ; 2, of the decom- 
position of proteids which produce besides the gases just 
mentioned sulphuretted hydrogen, carburetted hydrogen, 
and methyl mercaptan. The increased formation of gas is 
mostly due to an increased ingestion of easily fermenting 
food. 

A diminished elimination of the gases may be due : 1, 
to an inhibition of the passage of the flatus ; and 2, to re- 
tarded absorption. The passage of flatus is inhibited either 
by an intestinal obstruction or occlusion, or by a paresis 
or paralysis of the intestinal muscles. The latter condi- 
tion is found in peritonitis and in grave infectious diseases, 
after shock, in severe anaemia, in spinal affections, and 
also in general neuroses. Most cases of meteorism, which 
quickly appears and just as quickly leaves the patient, are 
due to paresis of the intestinal walls and are usually asso- 
ciated with a large number of other nervous symptoms. 

Symptomatology. — A certain degree of tension about the 
abdomen, more or less pronounced, is almost always expe- 
rienced by the patient. In some instances the abdomen 
protrudes in balloon-shape, the region of the navel being 
principally involved. This picture is mostly met with in 
patients with relaxed abdominal walls. In cases in which 
the latter are tense the accumulation of gases may push 
the diaphragm upward. Sometimes the lungs and heart 
are forced upward and severe dyspnoea develops, which 



METEORISM. 329 

in rare Instances may be followed by asphyxia, collapse, 
and even death. There is a constant feeling of press- 
ure and a desire to pass wind, while colicky pains are 
also occasionally met with. As a rule no flatus can be 
passed or very inconsiderable amounts at long intervals. 

Differing from the form of meteorism just described are 
those cases in which there is a slight tension over the abdo- 
men and wind is passed from the anus almost constantly 
for a long time with much noise. It is highly improbable 
that the gases emitted in this variety of cases are really 
produced in the intestinal tract for the following reasons : 
1, there is no considerable change in the size of the abdo- 
men after a repeated passage of considerable amounts of 
gas from the anus ; 2, the absence of relief felt by the pa- 
tient after the passage of flatus; and 3, the almost odorless 
character of these gases. Rosenheim compares these cases 
with those of nervous eructation from the stomach. While 
in the latter the air is constantly swallowed by the patient 
and belched up again, in the intestinal variety Eosenheim 
assumes that the air is constantly pumped into the rectum 
in order to be again emitted as flatus. 

The diagnosis of meteorism is made whenever an exces- 
sive amount of gas is discovered in the intestines. 

lUks prognosis will depend upon the cause which creates 
the tympanites. If it be due to organic lesions of the 
intestines (occlusion of the lumen) the prognosis is very 
grave, while meteorism clue to a purely nervous disturb- 
ance gives a favorable outlook. 

Treatment. — In instituting a curative plan for this affec- 
tion it will be necessary to elucidate the etiological factor 
of the meteorism. If the latter is caused by an obstruc- 
tion of the bowel, this primary affection will have to be 
treated as such. In most instances of meteorism of neu- 



330 DISEASES OF THE INTESTINES. 

rotic origin the following points are of importance : Drinks 
and foods containing or forming a large amount of gas 
should be prohibited; thus all carbonated waters, beer, 
champagne, and cider should be avoided. Fresh fruits, all 
kinds of cabbage, leguminous foods, potatoes, coarse rye 
bread, sweetened cake, rich gravies should be carefully ab- 
stained from. These rules apply not only when the mete- 
orism is fully developed but in patients with a disposition 
to flatulency. 

Formerly numerous intestinal antiseptics were given 
with the object of lessening the fermentative processes 
in the bowels. Recently, however, the general view pre- 
vails that they are of no benefit whatever. Benzonaphthol, 
salol, and salicylate of sodium are still regarded as the most 
efficient in this respect and may be tried in suitable cases. 
They can perhaps be advantageously administered in 
Sahli's ] glutoid capsules in order to prevent their ab- 
sorption in the stomach. Calcined magnesia, lime water, 
charcoal, testa prseparata, and subnitrate of bismuth are 
given with the intention of absorbing the gas, although 
their actual effect in this respect can naturally be only 
very limited. 

The following drugs are believed to have a beneficial 
influence in diminishing the gas, especially in mild forms 
of flatulency : poppy-seed, peppermint, spearmint, thyme, 
cinnamon, cloves, nutmeg, anise, fennel. These are best 
given in infusions. It has not as yet been scientifically 
proven whether the reaction following their administra- 
tion is due to a slight increase of the intestinal peristalsis. 
Brunton and Cash 2 are of the opinion that the carmin- 
atives, such as asafetida and oil of cloves, have a distinct 

1 Sahli : Deutsche med. Wochenschr. , 1897, No. 1. 

2 Brunton and Cash : St. Barthol. Hosp. Report, 1887. 



METEORISM. 331 

effect upon the absorption of several gases (carbonic-acid 
gas and sulphuretted hydrogen). 

The removal of the gas per vias naturales through the 
anus is the most efficient therapeutic measure. This can 
be done through cathartic remedies whenever there is no 
contraindication against their use. Large cleansing ene- 
mas of water, with the addition of a teaspoonful of essence 
of peppermint or oil of turpentine emulsified with an egg 
to a quart, are of benefit. 

When there are no anatomical lesions, massage of the 
abdomen and faradization may be of advantage. This 
also applies to friction of the abdomen with a. cloth dipped 
in some alcoholic solutions of aromatics or ethereal oils, 
(linimentum saponis, oleum carvi, cajuputi, terebinthina3, 
etc.). The introduction of a tube into the rectum maybe 
helpful in favoring the escape of gas from the lower parts 
of the colon. In desperate cases in which the meteorism 
has reached such dimensions as to endanger life, punc- 
ture of the intestine through the abdomen with the trocar 
has to be resorted to. The meteorism of hysterical per- 
sons often requires no treatment, as it usually disappears 
of itself. Sometimes, however, it is very obstinate to all 
therapeutic measures. 

SENSORY NEUROSES OF THE INTESTINES. 

While normally no sensations originate in the intestinal 
canal which become perceptible even during digestion, in 
pathological conditions this organ may be the seat of the 
most painful feelings. The latter originate in the fibres of 
the sympathetic nerve. Most of the sensory neuroses of 
the intestine consist in an increased excitability of the sen- 
sory filaments of these nerves. There are, however, a few 



332 DISEASES OF THE INTESTINES. 

conditions in which a lessened sensibility exists. The 
latter relates principally to the sensory nerves of the rec- 
tum. Normally the entrance of fecal matter into the rec- 
ium mechanically irritates these nerves and creates a desire 
ior an evacuation, while a lessened irritability of the rectal 
nerves may fail to produce the above sensation. 

Enteralgia. 

Synonyms. — Intestinal colic. Neuralgia mesenterica. 

Definition. — Pains in the intestines. 

Etiology. — Enteralgia is present in most organic lesions 
of the intestines. Enteralgia of purely neurotic origin, 
however, which is considered in this chapter, occurs inde- 
pendently of any anatomical lesions of the intestinal walls. 

Sometimes abnormally strong stimuli may be evolved 
within the intestinal canal, producing painful sensations. 
These stimuli may be of a mechanical, chemical, or ther- 
mal character. Thus, a conglomeration of intestinal 
worms, foreign bodies, gall stones, or enteroliths may pro- 
duce intense colic. Sometimes hardened fecal masses 
press upon the sensory nerves. The intestinal lumen 
being temporarily occluded by these masses, gases collect 
above this space and increase the tension within the intes- 
tinal canal, thus giving rise to intense pain (wind colic, 
colica natulans, which is quite often seen in children). 
Sometimes the ingestion of very coarse foods, indigestible 
substances, tainted foods, too cold beverages, highly fer- 
mented drinks cause enteralgia. In the gouty diathesis it 
may precede a gouty attack or replace it. Similar to these 
conditions in which the enteralgia takes its origin from 
toxic substances contained in the blood and irritating the 
intestinal nerves, is also the intestinal colic met with in 
chronic intoxication from lead or copper. 



ENTERALGIA. 333 

Aside from these forms of enteralgia due to a certain 
discoverable irritating factor, it may also result from a 
perverted state of the sensory intestinal nerves themselves. 
The latter group is principally found in patients affected 
with hysteria, or spinal troubles, although it may also be 
of a reflex nature due to abnormal conditions of neighbor- 
ing organs, kidneys, bladder, uterus, ovaries, and liver. 

Symptomatology. ■ — The symptomatology of enteralgia, 
presents quite a varied picture, in many instances depend- 
ing upon the cause of the enteralgia. If the neuralgia 
mesenterica is due to an error in diet, it usually begins 
with gastric disturbances, belching, nausea, vomiting, and 
anorexia. In cases in which an accumulation of fecal mat- 
ter produces the enteralgia, obstinate constipation and flat- 
ulence, occasionally alternating with diarrhoea, precede the 
attack. In chronic lead poisoning there are present a 
bluish line around the gums near the teeth, retarded pulse, 
and oliguria. 

The principal symptom of neuralgia mesenterica is pain 
within the intestine. It seldom appears suddenly and with 
great violence. As a rule, the pains are at first of light 
character and gradually increase in intensity. They are 
of a cutting, throbbing, or pinching nature, and are ex- 
perienced usually in one and the same abdominal area, 
most often in the region of the navel. Starting from this 
spot they radiate toward the back, the loins, the thighs, 
and the testicles. In some cases the pain wanders from 
one area to another and may be felt at different times in 
the most varied regions of the abdomen. In the latter 
instances the pains are accompanied by a visible peristaltic 
restlessness of the intestine, often producing gurgling 
noises. 

In mild cases the pain is quite endurable, and often lasts 



334 DISEASES OF THE INTESTINES. 

but a short while. In severer forms of enter algia, how- 
ever, the pains may be of extreme violence, and in weak 
patients may produce syncope, while in the more robust 
they may give rise to attacks of panting and crying. The 
face grows pale and assumes an expression of intense suf- 
fering. The forehead is covered with cold perspiration 
and the extremities are cold. The entire picture resem- 
bles very much that of shock. 

Pressure in many instances slightly alleviates the pain, 
and for this reason the patients often press their hand or 
some other hard substance against their abdomen. For 
the same reason they are often found lying on their abdo- 
men, pressing the latter against the mattress. In cases, 
however, in which the intestinal tract is filled with gas 
and the abdomen therefore in a tense condition, even very 
slight pressure increases the pains. Under these circum- 
stances a suspicion of peritonitis often arises. Ultimately 
the pains gradually decrease, and disappear much quicker 
if the accumulated fecal masses and gases have been evacu- 
ated spontaneously or by means of injections. The attack 
is then over. 

Spastic contractions of the intestine are often encoun- 
tered, especially when the pains are of intense character. 
If these contractions involve a large part of the intestine, 
as is often the case in lead colic, the abdomen appears 
trough-shaped. The abdominal walls are quite tense and 
often very rigid. In case the spasms are limited to iso- 
lated intestinal coils, the abdomen . is not drawn in and at 
some places where there are intestinal coils overfilled with 
fecal matter and gas, may asymmetrically protrude. In 
stercoral and wind colic the abdomen usually is tympanitic. 

Constipation is almost always present. Frequently 
there is also a retention of the intestinal gases. If the lat- 



ENTERALGIA. 335 

ter are passed in considerable quantity, the pains often 
subside for a short while, or, in some instances, especially 
in the so-called wind colic, entirely disappear. 

The intensity and the duration of the attack are subject to 
great variations. It may last from a few hours to several 
days. The pains are sometimes but very slight, aud again 
of such violence that even large doses of opium are hardly 
effective. 

Aside from the above-mentioned symptoms there exist 
quite often shortness of breath, palpitations of the heart, a 
sensation of oppression, tenesmus, strangury, hiccough, 
vomiting, seldom pollutions and priapism. Occasionally 
cramps of the calves and even general convulsions are ob- 
served. In cases of hysteria hyperesthesia of the abdomi- 
nal walls is encountered. 

Diagnosis. — Enteralgia is easily recognized when it pre- 
sents the above-described characteristic picture. Its neu- 
rotic nature, however, will be inferred from the following 
features : It appears in attacks, and subsides suddenly. 
There are almost always other nervous symptoms present. 
In enteralgia due to anatomical lesions of the intestine the 
pain is, as a rule, increased by pressure upon the abdomi- 
nal walls. Another distinguishing mark for the latter is 
that it is more often accompanied by diarrhoea, and that 
ihe dejecta contain pathological admixtures (blood, mucus, 
rarely pus). 

With regard to the differential diagnosis the following 
conditions which are accompanied by abdominal pains will 
have to be excluded : Rheumatic affections of the abdomi- 
nal muscles, lumbar abdominal neuralgia, hyperesthesia 
of the abdominal walls, peritonitis, biliary and renal colic. 

Rheumatism of the abdominal muscles is characterized 
by the following features : The pain is situated over the 



336 DISEASES OF THE INTESTINES. 

superficial area and not within the abdominal cavity. It 
often changes its seat. It is of longer duration than enter- 
algia and does not show any distinct exacerbations nor 
diffusion. Pressure increases the pain, while rest in a re- 
cumbent position eases it. Anti-rheumatic remedies (salol, 
sodium salicylate, salipyrin) subdue it. 

In lumbar abdominal neuralgia the pain is localized on 
the surface and limited to one intercostal space which is 
very painful to pressure. The pains often radiate to the 
back, the hypogastrium, and the genital organs. Anti- 
neuralgic remedies (antipyrin, antifebrin, phenacetin) are 
often efficient. 

Hyperesthesia of the abdominal wall is, as a rule, met 
with in hysteria and neurasthenia. The pains are local- 
ized in the superficial layer. The slightest touch of the 
skin of the abdomen increases the pain. The faradic cur- 
rent often quickly removes it. 

In peritonitis there is almost always fever, and the pain 
is increased on pressure. Meteorism is here much more 
frequently encountered than in intestinal colic. Frequently 
dalness in the lower part of the abdomen (exudation) is 
observed. 

Biliary and renal colic are recognized by the situation 
of the pain which often corresponds to the location of the 
affected organ. Besides, other symptoms are usually pres- 
ent which are characteristic of the latter (icterus, strangury). 

Prognosis. — The prognosis of intestinal colic is almost 
always good with regard to life, for the attack usually ends 
in recovery. Exceptional cases of death have, however, 
been observed by Oppolzer 1 and Wertheimer. 2 

Treatment. — The treatment consists, first, in measures 

1 Oppolzer: Wiener med. Wochenschr., 1867. 

3 Wertheimer : Deutsches Arch. f. klin. Medicia, 1866, Bd. 1. 



ENTERALGIA. 337 

directed toward the removal of the cause, and secondly, 
toward the relief of the pain. In most cases of intestinal 
colic a thorough evacuation of the bowels is of benefit. 
For this purpose injections of a considerable quantity of 
water (one to two quarts) or of olive oil (one-half to one 
pint) are very serviceable. Mild cathartic remedies, cas- 
tor-oil, calomel, and the like, may also be administered. 
In cases in which worms have been found a vermifuge must 
be given with the cathartic. If meteorism is quite pro- 
nounced massage of the abdomen may be tried. If the 
colic is due to an error in diet, the latter must be strictly 
regulated. If due to a general cold, hot beverages (tea, 
infusions of camomile and of peppermint), hot poultices 
over the abdomen are of value. 

In nervous enteralgia occurring in patients suffering from 
hysteria and neurasthenia the treatment should be directed 
toward the improvement of the latter conditions. Climate, 
electricity, massage, and hydrotherapy play a predominant 
part here. 

The following symptomatic measures which serve to 
subdue the pains are of great importance : If the colicky 
pains are quite severe, the administration of an efficient 
dose of an opiate is indicated. Tincture of opium may be 
given in doses of fifteen or twenty drops, or opium ex- 
tract, 0.03 to 0.05; or morphine, 0.01 to 0.015, may be in- 
jected subcutaneously. Even in cases in which the colic 
is due to a retention of fecal matter, the narcotics just 
mentioned are indicated, for they relieve the spastic con- 
tractions of the intestines. 

During a severe attack of intestinal colic the diet should 

consist principally of liquids, small quantities of milk and 

broth being given at frequent intervals (about every two 

hours) . If the attacks recur quite often, the application 
22 



338 DISEASES OF THE INTESTINES. 

of the galvanic current (one electrode within the rectum, 
negative pole, the other over the abdomen) is sometimes 
of benefit. 

Hypogastric Neuralgia. 
(Neuralgia hypogastrica, Komberg. 1 ) 

Enteralgia limited to the lower portion of the large 
bowel is termed hypogastric neuralgia. In this condition 
there exist disagreeable, sometimes painful sensations in 
the lower region of the abdomen and in the lower parts of 
the back, accompanied by a violent feeling of pressure in 
the rectum and sometimes also in the bladder. In female 
patients the same sensation may also extend to the uterus 
and vagina. Sometimes the patient also complains of 
painful sensations in the perineum and the thighs. Per- 
sons suffering from hemorrhoids and women afflicted with 
nervous and uterine troubles are principally liable to suffer 
from this condition. This form of neuralgia is also fre- 
quently found in diabetic patients. Sometimes the pa- 
tients have the sensation as if a foreign body were in the 
rectum. 

The treatment resembles very much that of intestinal 
colic. The original trouble predisposing to hypogastric 
neuralgia should always be first treated. If congested 
piles are present, application of leeches about the anus 
and warm sitz baths must be recommended. If the pains 
are violent, suppositories of opium alone or with bella- 
donna should be used. The diet should be a bland one 
and the bowels should be carefully regulated. 

1 Romberg : "Lehrbuch der Nervenkrankheiten," Berlin. 



HYPERESTHESIA. 339 

Hyperesthesia, Paresthesia, and Anaesthesia of the 
Intestine. 

While in the normal state no disagreeable sensations are 
manifested during the act of intestinal digestion and defe- 
cation, in some cases of neurasthenia or listeria we meet 
with exceptions to this rule. Thus, even without apparent 
anatomical lesions of the intestine, there may be a sensa- 
tion of pressure, fulness, of pinching, of heat or cold in the 
lower region of the abdomen a few hours after the inges- 
tion of food. The same sensations may also occasionally 
appear without the patient having eaten anything, after 
bodily exertion and excitements, especially after sexual 
intercourse. 

The rectum and the anus are particularly liable to be 
the seat of abnormal sensations. Physiologically a feel- 
ing of fulness is experienced in the rectum when the fecal 
mass has accumulated in this locality. In case of neuras- 
thenia a sensation of fulness with an inclination to go to 
stool may appear, even when the rectum is entirely empty. 
Sometimes a feeling of pressure or weakness in the anal 
region may be present; sometimes the patient may be 
tormented by a constant burning or itching in the same 
region. The act of defecation may be accompanied by 
erections, sometimes by a feeling of uneasiness; quite 
often a feeling of extreme fatigue after defecation is ex- 
perienced. 

Anaesthesia of the rectum is observed in the same class of 
patients. The sensation of fulness in the rectum, which 
causes the desire for defecation, is then absent; there is, 
therefore, never a desire for evacuation. In very pronounced 
cases of rectal anaesthesia it may occur that even the pas- 
sage of fecal matter through the anus is not felt. Such a 



340 



DISEASES OF THE INTESTINES. 



high degree of anaesthesia, however, is met with only in pa- 
tients with spinal and brain troubles and in very old and 
decrepit individuals. Paralysis of the sphincters, which 
has been described above, may occasionally accompany 
the anaesthesia of the rectum and thus aggravate the latter. 
In such instances involuntary evacuations of the bowels 
take place without the patient's knowledge. He becomes 
aware of this fact only after his clothes have been soiled 
and by the fecal odor. 

In the treatment of these abnormal sensations within the 
intestines attention must be directed toward the improve- 




-Rectal Obturator. 



ment of the general condition, thus raising the nervous 
tone of the organism. Hydrotherapeutic measures and 
climatic influences are of the greatest importance. While 
dietetic measures as such are without much influence upon 
the nervous disturbances which appear during the intesti- 
nal digestion, spicy food and alcoholic beverages should, 
notwithstanding, be forbidden and an essentially vege- 
tarian regimen recommended. The abnormal sensations 
within the rectum and anus may be improved by cooling 
rectal douches, by sitz baths, and also by rectal galvani- 
zation. 

In cases of anaesthesia of the rectum a cleansing enema 
in the morning will remove the fecal matter and thus be 
beneficial during the day. Patients suffering from the 



MEMBRANOUS ENTERITIS. ; >-tl 

severer forms of anaesthesia should wear a rectal obturator 
held in place by means of a T-bandage during the day 
(Fig. 39). 

SECRETORY NEUROSES OF THE INTESTINES. 

Although there is no doubt that secretory nerves exist in 
the intestines — for it has been shown that the entrance of 
food into the stomach is immediately followed by secre- 
tion not only in the small intestine but also in distant 
parts of the large bowel — still we are yet very far from the 
knowledge of their exact location. Nervous diarrhoea, 
which has been described under the motor neuroses, is 
often accompanied also by an increased flow of intestinal 
juice. Conditions in which there is a lessened secretion 
of intestinal juice are not yet positively known. It may 
be that they exist in cases of constipation, being perhaps 
the cause of the latter in some instances. While, however, 
in the disturbances just mentioned the increase or decrease 
of intestinal secretion is a mere hypothesis, one affection 
of the intestines exists in which increased secretion is posi- 
tively found. This is the so-called membranous enteritis. 

Membranous Enteritis. 

Synonyms. — Mucous Colic; Tubular Diarrhoea; Mem- 
branous Diarrhoea. 

Definition.— By membranous enteritis is understood an 
affection in which more or less large pieces of mucus (usu- 
ally ribbon-like) are passed periodically with the faeces. 

History. — This affection seems to have been familiar to 

the medical world for several centuries. Paulus iEgineta, 1 

in speaking of the passage of the inner membrane of the 

1 Paulus vEgineta : Cited from Da Costa, American Journal of the 
Medical Sciences, 1871, p. 321. 



342 DISEASES OF THE INTESTINES. 

intestine, has certainly dealt with cases of membranous 
enteritis, and erred only in the explanation of these 
masses. 

Sennertius and Morgagni ] recognized these membranes 
as mucus, which had been inspissated and moulded in the 
intestine. 

Mason Good 2 was the first to describe this affection un- 
der the name of "tubular diarrhoea," which name has also 
been accepted by Woodward. 3 The latter author adds that 
in case the membranes in a given instance have no tubu- 
lar form, the expression " membranous diarrhoea " is suit- 
able. 

F. Siredey 4 contributed a very valuable paper in 1869 
in reference to the knowledge of this affection. He de- 
scribed one case of mucous discharge in a man and six 
cases in women, and arrived at the conclusion that in some 
instances these mucous discharges occur in patients whose 
intestinal tract does not reveal any organic lesion whatever. 
For this reason Siredey regards this affection as an in- 
testinal neurosis, occurring principally in hypochondriacs 
and hysterics. 

Whitehead 5 describes this affection under the name of 
"mucous disease," cites the entire old literature, and gives 
detailed rules with regard to treatment and diet. He 
says : " Exercise, short of fatigue, should be taken daily. 

1 Sennertius and Morgagni : Cited from J. G. Woodward, " The 
Medical and Surgical History of the War of the Rebellion, " 1879, part 
ii., vol. i., p. 363. 

2 Mason Good: "The Study of Medicine," cl. 1, ord. 1, species 7, 
vol. i., Philadelphia, 1825, p. 162. 

3 Woodward : Loc. cit. 

4 Siredey, F. : " Note pour servir a 1' etude des concretions muqueuses 
membraniformes de l'intestin. " Union med., Nos. 7-9, 1869. 

5 Whitehead, W. : "Mucous Disease." British Medical Journal, 
February 11, 1871, p. 140. 



MEMBRANOUS ENTERITIS. 343 

The diet is perhaps the point of all others where the great- 
est mistake is made. An idea, strongly felt by the patient, 
that a great amount of strengthening food is required, 
leads to the further exhaustion of an already enfeebled 
digestion. Impress upon the patients the fact that it is 
the quantity absorbed which means strength, and not the 
bulk swallowed, and it is possible to check the error they 
are so anxious to commit. Certain articles of diet should 
be strictly interdicted, the chief of which are the follow- 
ing : Liquid food, excepting milk, aggravates in the major- 
ity of cases every symptom; sugar is invariably hurtful; 
tea, coffee, and alcohol — Burgundy being the only wine 
from which I have ever derived benefit — vegetables, and 
fruit also prove injurious." 

Cruveilhier l and Laboulbene 2 discuss this ailment under 
the term "pseudo-membranous enteritis." 

One of the best papers upon this disease was written by 
Da Costa, 3 who called it "membranous enteritis." This 
author gave a lull description of this affection, recognized 
its nervous character, furnished several detailed cases, and 
put particular stress upon dietetic treatment. Da Costa 
permits eggs, milk, bread, and solid food, which is better 
borne than liquids; tea, coffee, and alcoholic stimulants 
are to be permitted only in very small quantities. As re- 
gards vegetables, we must observe whether they pass un- 
changed in the stools. Fresh meat juice is serviceable; 
from an exclusive milk diet, even faithfully carried out, he 
has seen no good. Furthermore, Da Costa recommends 
that great attention be paid to the action of the skin, and 

1 Cruveilhier : Anat. path, gen., t. ii. 

2 Laboulbene : "Recherches sur les affections pseudomembraneuses, " 
1861. 

3 J. M. Da Costa : "Membranous Enteritis." American Journal of 
the Medical Sciences, 1871, p. 321. 



344 DISEASES OF THE INTESTINES. 

believes baths followed by systematic friction to be very 
useful. Daily moderate exercise is advocated, particularly 
in cool weather, and if possible an occasional trip to the 
mountains and living out of doors in the bracing mountain 
air. Everything that can be done to invigorate the diges- 
tive and nervous systems forms the essential part of the 
therapeutics. 

A few years later there appeared an article by Edwards, 1 
who coincided with Da Costa's views in most points, 
being, however, much stricter with regard to diet. He 
says: "Easily digested or even predigested food should 
be supplied, and care should be taken that undigested 
particles of food are not irritating the intestinal canal." 

Ley den, 2 in 1882, directed attention to membranous en- 
teritis in Germany, where also very soon appeared ex- 
haustive publications on this subject. Nothnagel 3 sug- 
gested the name "colica mucosa," in order to show that 
a true enteritis need not exist in these cases and that the 
disease really is a mucous colic. Eothmann 4 was the first 
to publish a case of membranous enteritis — complicated 
with cancer of the skull — in which an autopsy was made. 
By means of Weigert's stain, or rather by Ehrlich-Hoy- 
er's thionin (a specific stain for mucus), double-stained 
specimens could be obtained, which showed the presence 
of large quantities of mucus on the surface of the large 
bowel in the glandular tubules. 

1 Edwards : American Journal of the Medical Sciences, April, 1888, 
p, 829. 

2 E. Leyden : Verhandl. d. Vereins f. innere Medicin in Berlin, 
Deutsche med. Wochenschr., 1882, Nos. 16 and 17. 

3 Nothnagel : " Colica mucosa. " Beitrage zur Physiologie .und 
Pathologie des Darms, " 16tes Capitel, 1884. 

4 Max Rothmann : "Ueber Enteritis membranacea. " Deutsche med. 
Wochenschr., 1893, p. 999. 



MEMBRANOUS ENTERITIS. 345 

Ewald, 1 Boas, 2 Kittagawa, 3 Pariser, 4 and others have 
added further contributions. 

Ewald laid stress on a ptosis of the colon, Boas on atony 
of this organ as important factors in this affection. 

Etiology. — Most authors agree that membranous enteritis 
is quite a rare affection ; it occurs much more frequently 
in women than in men (children being only exceptionally 
affected). 

That the nervous element (hysteria, neurasthenia) plays 
a great role in the origin of this trouble, no one can doubt, 
and W. Mendelson 5 is right when he asserts that neuras- 
thenia is not absent in any of his cases. Mendelson goes 
too far, however, when he says : " I believe that the reverse 
of the proposition may also as confidently be affirmed — 
namely, that if neurasthenic patients be closely questioned, 
very few will be found who have not had at some time re- 
peated characteristic passages of stringy mucus, associated 
with abdominal pains." Membranous enteritis is found 
in nervous individuals (possibly the affection as such adds 
much to their neurasthenia) ; but only a small fraction of the 
great mass of neurasthenics is afflicted with this ailment. 

With regard to the frequency of membranous enteritis, 
1 examined my private patients of the year 1897 relative 
to its presence, and take the following data from my day- 
book. The total number of patients was 1,315 — 772 men, 
543 women. Twenty of these patients suffered from mem- 

1 C. A. Ewald: "Membranous or Mucous Enteritis." Twentieth 
Century Practice of Medicine, vol. ix., p. 265. 

2 J. Boas: Deutsche med. Wochenschr. , 1893, No. 41. 

3 O. Kittagawa: "Beitrage zur Kenntniss der Enteritis membrana- 
cea." Zeitschr. f. klin. Medicin, 1891. 

4 Pariser: Deutsche med. Wochenschr., 1893, No. 41. 

6 Walter Mendelson : " Mucous Colitis a Functional Neurosis. " 
Medical Record, January 30, 1897. 



346 DISEASES OF THE INTESTINES. 

branous enteritis — two men and eighteen women. The 
frequency of membranous enteritis among sufferers from 
digestive disorders expressed in percentages is, in men, 
0.25 per cent; and in women, 3.31 per cent. Among these 
twenty patients, twelve had enteroptosis in a pronounced 
degree. Ewald has already pointed out that a prolapse 
of the colon is frequently found in patients with mem- 
branous enteritis. My own observations fully confirm this 
statement, for with the prolapse of the stomach descent of 
the colon naturally must be presupposed. It appears that 
enteroptosis certainly creates a fruitful soil for the devel- 
opment of membranous enteritis, although it does not di- 
rectly cause it. Enteroptosis is, as is well known, very 
frequent, while membranous enteritis is rare in compari- 
son with the former. There must, therefore, be still other 
factors which are of importance in the causation of mem- 
branous enteritis. 

With reference to gastric secretion and the motor func- 
tion of the stomach in this disease, 1 2 have made examina- 
tions on twelve cases and found the following two points 
most conspicuous : 

1. The motor function (prochoresis) of the stomach — 
judged from the amount of contents found one hour after 
the test breakfast — was increased in eight cases and nor- 
mal in the four remaining. 

2. Five cases presented a typical achylia gastrica. 

Considering the comparative infrequency of achylia gas- 
trica, which hardly amounts to two or three per cent of the 
digestive disorders, this large proportion of achylia in pa- 
tients with membranous enteritis — namely, five in twelve — 
is certainly noteworthy. 

1 Max Einhorn : " Membranous Enteritis. " Medical Record, January 
28, 1899. 



MEMBRANOUS ENTERITIS. 347 

Three cases of membranous enteritis with normal acid- 
ity revealed, besides the increased prochoresis, still another 
feature in common with achylia — namely, the extraordi- 
narily small amount of fluid surrounding the scarcely 
changed particles of roll, one hour after the test breakfast. 
Although this symptom may occasionally be met with in 
other cases than achylia, it is nevertheless, as a whole, 
characteristic of this affection. Therefore we are justified 
in making the following statement : In many cases of mem- 
branous enteritis typical achylia is present, in some it is 
lacking, but even then some features characteristic to achy- 
lia are encountered. In membranous enteritis achylia thus 
plays a great part. Whether one condition causes the 
other, or one and the same factor (nervous influences) cre- 
ates both, is difficult to say. The latter, however, is more 
plausible. 

Symptomatology. — The disease is characterized by at- 
tacks of rather violent colicky pains in the abdomen, which 
are followed by the passage of mucous masses with the 
stools. The mucus may be voided either alone, without 
any admixture of fecal matter, or it forms a considerable 
part of the evacuation. Usually the attack is preceded by 
a period of obstinate constipation, and often followed by 
diarrhoea lasting a few days, and sometimes accompanied 
by tenesmus. Gastric symptoms— as loss of appetite, fre- 
quent belching, now and again a burning sensation at the 
pit of the stomach — are generally quite pronounced during 
the attack. Vomiting may occasionally appear, while fever 
is, as a rule, absent. The attack lasts three to seven days, 
and then the pains subside, the diarrhoea ceases, and eu- 
phoria reappears. More or less constipation, however, 
and some other dyspeptic as well as nervous symptoms 
persist. These free intervals last various periods of time 



348 DISEASES OF THE INTESTINES. 

(four weeks to five or six months). In rare instances the 
mucous discharges may be present continuously. 

With reference to the mucous masses, they present a 
grayish-white appearance, seldom yellowish, and have 
either a ribbon-like or membranous form; at times the 
pieces are several feet long; ordinarily, however, they are 
considerably smaller. Complete moulds of the intestinal 
lumen have been observed by several authors, and Ley den 
not unjustly has compared this process with that of croup 
of the larynx. As already stated by Cornil, 1 the false 
membranes consist of mucus, mixed with dried-up epithe- 
lial ovoid cells, which arise from a mucous metamorphosis 
of the cylindrical cells or the leucocytes. Nothnagel 
and others have proven the mucous nature of these dis- 
charges. 

As suggested by Pariser, the mucous nature of these 
masses can be demonstrated by treating them, first, with 
sublimate alcohol, and then staining them with Ehrlich's 
triacid solution. A green color appears, which indicates 
mucus (fibrin treated in the same manner assumes a red 
color). Judging from my experience it is unnecessary to 
dip these membranes first into sublimate alcohol, as the 
same result will follow when they are put directly into the 
weak triacid solution. Microscopically this substance re- 
veals a somewhat fibrillary nature, and contains many 
shrivelled cells, so called by Nothnagel. Micro-organisms 
are found admixed, although they do not seem to play any 
important part in this affection. In two of my cases mi- 
croscopically single-celled corpuscles were found in these 
masses, having a distinct nucleus and a tail-like process. 
The accompanying drawing shows these corpuscles /Fig. 
40). These are most probably metamorphosed goblet cells. 
1 Cornil : Cited from Siredey. See above. 



MEMBRANOUS ENTERITIS. 



349 



Diagnosis. — The diagnosis of membranous enteritis is, 
as a whole, simple when the above-mentioned character- 
istic symptoms, including the mucous discharges, are jjres- 
ent. It is, however, necessary to be careful not to mis- 
take for mucus other substances admixed in the faeces, 




Fig. 40.— Microscopical Picture of Mucous Masses Found in the Evacuation of Mrs. L., 
Showing Numerous Cells Having a Nucleus and a Tail-like Process. 



which occasionally resemble shreds of mucous membrane 
— as, for instance, the fibre of an orange, tendons, pieces 
of tapeworm. A microscopical examination will guard 
against all such errors. 

This affection will hardly be confounded with real intes- 
tinal catarrh, as it presents an entirely different picture 
and only occasionally may have an abundant secretion of 
mucus in common with mucous colic. There are, however, 



350 DISEASES OF THE INTESTINES. 

cases of chronic intestinal catarrh which are complicated 
with membranous enteritis — that is, having typical attacks 
of mucous colic. The following case presents an instance 
of this kind : 

Miss L. N , twenty-eight years old, had diarrhoea 

eleven years ago for quite a while, which disappeared after 
two or three months. The patient was then well until 
four years ago, when she again began to be troubled with 
diarrhoea. Soon periods of obstinate constipation ap- 
peared, which alternated with diarrhoea. The patient re- 
ports having occasionally observed mucus in the passages ; 
s>t times (about every five or six weeks) there appear 
abdominal pains for about one or two hours, followed by 
an evacuation of pure mucus, the quantity being one to two 
tablespoonfuls. The appetite was always good. Now and 
again there was belching. The patient lost about twenty- 
five pounds in weight. Sleep is undisturbed, only at times 
restless for a few days. Her strength greatly failed. Pal- 
pation of the abdomen reveals spots sensitive to pres- 
sure in the entire course of the colon. The examination 
of the fseces in the free interval shows small quantities of 
mucus well mixed with the fecal matter. The mucous 
masses voided after an attack of pains are free from fecal 
matter, appearing grayish-white and staining green when 
treated with Ehrlich's triacid solution. 

Treatment. — Diet plays the principal part in the treat- 
ment of membranous enteritis. While the older writers 
laid stress on scanty light food, it is now generally ac- 
cepted that abundant nutrition is of the greatest value. 
That a fluid diet is unsuitable, the older authors have al- 
ready been cognizant of (Da Costa, Whitehead, Siredey), 
and this axiom holds good in its entirety even to-day. 

Eecently von Noorden ' advised a very coarse diet, being 

1 C. von Noorden: "Ueber die Benandlung der Colica mucosa." 
^Zeitschr. f. practische Aerzte, 1898, No. 1. 



MEMBRANOUS ENTERITIS. 351 

guided by the idea that the intestinal tract should be exer- 
cised and strengthened by increased work. He recom- 
mends per day half a pound of bread containing plenty of 
chaff, leguminous vegetables, garden vegetables rich in 
cellulose, fruits with small pits and coarse skin, as cur- 
rants, gooseberries, grapes — these being foods rich in un- 
digestible material, thus forming much ballast for the 
bowel. Among fifteen patients subjected to this treatment 
by von Noorden, seven were permanently cured, seven im- 
proved, and one was unchanged. 

This method has certainly much in its favor; it may be 
better, however, not to institute this diet abruptly, as sug- 
gested by von Noorden, but rather gradually. 

I, for my part, for some years past have seen to it that 
my patients partook of an abundant and nutritious diet, 
without, however, advising substances that were too coarse. 
As a whole, I recommend ample food and try to keep the 
patients on a mixed diet containing plenty of vegetables. 
In patients who have lived on a strict diet (as for instance 
milk diet or beef and hot water), I arrange the change 
gradually. The principle here is the same as stated by 
von Noorden, only not carried to such an extreme. It ap- 
pears sufficient if the intestines of the patient with mem- 
branous enteritis are trained to master the foods customary 
in healthy persons, and the accomplishment of this object 
is all that is required. If we subsequently see that the 
organism amply fulfils its work, a few less digestible foods 
may then be added. It is not necessary to recommend 
these immediately from the start, nor are they important 
for the cure. 

With regard to therapeusis, two phases will have to be 
considered — the treatment during the attack and the treat- 
ment during the interval. In severe attacks, rest in bed, 



352 DISEASES OF THE INTESTINES. 

warm poultices over the abdomen, a cleansing enema (of 
ordinary warm water with the addition of some common 
table salt or essence of peppermint — one teaspoonful to a 
quart) , and afterward the administration of codeine or 
opium, with or without belladonna, are of value. As long 
as the pains last it is necessary to give light food (small 
quantities frequently) . In mild attacks a stay abed may 
not be requisite, nor the administration of an analgesic 
remedy, and the diet may be the same as during the in- 
terval. 

In the interval free from pains the treatment consists in 
a methodical application of olive-oil enemas, as suggested 
by Kussmaul and Fleiner. * These enemas are injected into 
the bowel at night, at blood temperature, the quantity being 
two hundred and fifty to Rye hundred cubic centimetres. 
The patient is then instructed to try and retain the oil in 
the bowel during the night. The patients seldom assert 
that they are disturbed in their sleep by these injections 
and have to answer nature's call. In such an instance the 
quantity of oil may be reduced to one hundred and fifty or 
one hundred cubic centimetres. The oil should be injected 
every night for three weeks; then every other night for 
three weeks, and twice weekly for four weeks ; finally, once 
weekly for five or six months. Besides, patients must 
accustom themselves to a regular morning evacuation, by 
promptly visiting the closet every day at the same hour in 
the morning. 

Next to abundant nourishment the methodical oil cure 
is of the greatest importance in the treatment of this 
affection, and the results achieved are, according to my 
experience, very satisfactory. The administration of oil 
injections in membranous enteritis is mentioned here and 
1 Fleiner . Berliner klin. Wocbenschr. , 1893, No. 3. 



INTESTINAL NEURASTHENIA. 353 

there in recent literature, especially by Ewald, but its 
value must be placed much higher than heretofore. The 
oil has not only a favorable influence upon the constipa- 
tion which is always present in this malady, but at the 
same time also effects a diminution or a disappearance of 
the mucous discharges. How the oil brings this about is 
difficult to say. The favorable effect may perhaps be ex- 
plained by the circumstance that by means of the oil the 
intestine is not left in an empty condition during the 
night, and thereby a spasmodic contraction is avoided, 
which must be regarded as one of the principal factors in, 
the formation of mucus. 

It is evident, according to my statement with regard to 
the etiology, that enteroptosis and anomalies of the gas- 
tric functions (principally achylia) exist in a large number 
of these cases. It will, therefore, be necessary to bear 
these points in mind and to treat the cases accordingly. 
The neurotic symptoms present in these cases should not 
be neglected in the general plan of treatment. We shall 
have to pay attention to a regular hygienic mode of living 
and ample physical exercise. In suitable cases occasional 
hydrotherapeutic measures will be of value. The tonic 
remedies, like iron, arsenic, etc., will also prove beneficial. 

Intestii i al Neurasthenia . 

The various intestinal neuroses have been separately 
described. In practice combinations of different neuroses 
frequently occur. Following Rosenheim we designate such 
cases as intestinal neurasthenia. The appetite as a rule 
is good and the symptoms usually appear during the pe- 
riod when intestinal digestion takes place. The symptoms 
generally develop one to three hours after meals and consist 

in a feeling of pressure, tension, and sometimes of griping 
23 



354 DISEASES OF THE INTESTINES. 

in the abdomen. Occasionally there may be a sensation 
of nausea, at times an evacuation of the bowels accompa- 
nied with painful sensations in the abdomen and in the 
anus. Sometimes palpitation of the heart occurs, some- 
times again a sensation of flashes of heat or of cold extend- 
ing upward. As a rule, the patients feel worse when rest- 
ing, especially in the recumbent position, than when 
walking about. After a period of one or two hours the 
symptoms usually disappear, to return again later on after 
a meal. 

Constipation is as a rule associated with this condition. 
The quality of the food does not seem to exert much 
influence upon the symptoms, although the latter are 
more marked after heavier meals. In a few instances, es- 
pecially when the pains play a predominant part and bor- 
borygmi occur, diarrhoea is encountered. In these cases 
the diarrhoea appears in the middle of the night or toward 
early morning, and disturbs the patient's sleep. It is 
of diagnostic importance that the pains do not in any way 
depend upon the quality of the food. Indigestible foods, 
even taken in considerable quantity, are occasionally well 
borne, while at other times a small meal, consisting of the 
lightest food, causes severe symptoms. Intestinal neuras- 
thenia is sometimes associated with gastric neurasthenia 
and completes the picture of the other. 

In making the diagnosis of intestinal neurasthenia ana- 
tomical lesions of the intestines must first be excluded. 

The treatment consists in hygienic measures which serve 
to tone up the system, in ample feeding, and in the admin- 
istration of the bromides, occasionally in conjunction with 
iron and arsenic. With regard to diet all foods are al- 
lowed excepting indigestible substances, and a preponder- 
ance of vegetable food is to be recommended. 



CHAPTER XII. 

INTESTINAL PAEASITES. 

General Remarks. — Most of the animal parasites found 
in man inhabit the intestinal canal. Leuckart 1 estimates 
the number of varieties at about fifty. Not all parasites, 
however, produce morbid conditions. Comparatively few 
of them evoke a pathological state, either in the intestine 
by their direct presence, or in the blood by the formation 
of toxic products which are absorbed and reach the circu- 
lation. The intestinal parasites are detected by repeat- 
edly examining the stools. They may be seen or their 
presence may be assumed from the discovery of their ova 
(the latter referring to the helminths). There are no char- 
acteristic symptoms which would be encountered only in 
morbid conditions due to animal parasites. The diagno- 
sis, therefore, must be made by directly discovering them 
or their eggs in the dejecta. It will always be wise to look 
for worms in cases in which gastric and intestinal symp- 
toms of a functional character exist, accompanied or not 
by anaemia and certain neuropathic affections. The intes- 
tinal parasites are divided into two large groups : (1) Pro- 
tozoa. (2) Vermes. 

I. PROTOZOA. 

Amoeba?. 

Besides dysenteric amoebae which have been described 
above, a similar variety is occasionally encountered giving 
'Leuckart: "Die menschlichen Parasiten, " Leipzig, 1886, Bd. ii. 



356 DISEASES OF THE INTESTINES. 

rise to no symptoms whatever or sometimes to slight at- 
tacks of diarrhoea. 

Sporozoa. 

Among the sporozoa coccidia are occasionally found in 
the stools. This organism is egg-shaped, provided with 
a thin shell, 0.02 mm. long, and contains in its interior a 
large number of nuclei usually arranged in groups. The 
coccidia do not seem to have any pathological bearing. 

Infusoria. 

To these belong cercomonas intestinalis, trichomonas 
intestinalis, and paramsecium coli. All of them are found 
principally in conditions in which diarrhoea is the fore- 
most symptom. 

The cercomonas intestinalis is pear-shaped, has a distinct 
nucleus and eight flagellse. The head portion of the body 
tapers obliquely and presents a depression (Fig. 41). It 
is not believed to have a direct pathogenic significance. 



Sr 




Fig. 41.— Cercomonas Intestinalis (Da- Fig. 42.— Trichomonas Intestinalis (Zun- 
vaine). ker). 

It is assumed, however, that this micro-organism is liable 
to prolong pre-existing catarrhal affections of the intestine. 

Trichomonas intestinalis presents the same features as 
the cercomonas and can be distinguished from the latter by 
its somewhat greater size and the row of fine cilia upon the 
periphery of its body (Fig. 42). In fresh dejecta this mi- 
cro-organism moves around very actively. Zunker 1 found 

bunker: Deutsche Zeitschr. f. praktische Medicin, 1878, No. 1. 



TAPE WORMS. 



357 




it principally in mushy dejecta having a brownish-yellow 
color and a somewhat putrid odor. 

Paramecium (or balantidium) coli is egg-shaped, 0.1 mm. 
long and covered with fine cilia, the latter being densely 
grouped about the mouth, while but few of them surround 
the anus. In the interior of this or- 
ganism are found a nucleus and two 
contractible vesicles, besides fat drop- 
lets, starchy particles, etc. (Fig. 43). 
The balantidium coli was first de- 
scribed by Malmsten ' in 1857. In 
the fresh stools the balantidium moves 
about very rapidly, but it dies as early 
as one-half an hour to two hours after 
the dejecta have been passed. Like 
the cercomonas, the paramaeciuni coli 
is believed to keep up conditions of 
diarrhoea. 

The treatment directed against these 
infusoria consists in intestinal irriga- 
tion with watery solutions of tannic acid, boracic acid, 
thymol, or quinine. 

II. VERMES. 
Cestodes (Tape Worms'). 

General Remarks. — In describing the disorders caused 
by tapeworms it is best to include the taenia solium, taenia 
mediocanellata, and bothriocephalus latus. 

The symptoms produced by these three different entozoa 
are almost identical. In some instances the tapeworm is 
domiciled in the intestine for a long period of time with- 
out manifesting any symptoms. The host may enjoy per- 
1 Malmsten; Virchow's Arcliiv, Bd. xii. 



Fig. 43. — Balantidium 
Coli (Glaus), a, Mouth; 
b, nucleus ; c, a granule 
of starch which has 
been ingested ; d, a for- 
eign body in the process 
of being expelled. 
Highly magnified. 



358 DISEASES OF THE INTESTINES. 

feet health and only after noticing segments of taenia in the 
dejecta does he become conscious of his uninvited guest. 
In other instances the worm produces intestinal as well as 
general disturbances. A feeling of pressure at the pit of 
the stomach and pains at different points of the abdomen 
may be present. Bulimia is frequently encountered. 
Anorexia and anorexia alternating with bulimia are also 
occasionally observed. Nausea, even vomiting, may be 
present, especially in the morning. The bowels are usu- 
ally constipated. In a few instances, however, there is 
persistent diarrhoea. 

Besides these gastro-intestinal symptoms there may be 
present various disturbances of the nervous system or of 
the blood; dizziness, headache, fainting spells, convul- 
sions, epilepsy, various forms of paresthesia of the ex- 
tremities. Some patients, again, look very bad and be- 
come emaciated, notwithstanding that they take sufficient 
quantities of food. The anaemic condition is occasionally 
very marked. The patient feels extremely weak, suffers 
from palpitation of the heart, is hardly able to walk, and 
is subject to fainting spells. In this serious form of anae- 
mia oedema of the feet and eyelids may exist as well as 
hemorrhages from the mucous membranes. The micro- 
scopical examination of the blood in these instances reveals 
poikilocytosis and also nucleated red blood corpuscles, 
thus demonstrating the existence of a progressive per- 
nicious anaemia. The grave condition just described has 
been observed only in the presence of bothriocephalus 
latus but not of the other varieties of tapeworms. 

The proof that the symptoms described are produced 
by the tapeworm is found in the circumstance that they 
disappear entirely after the removal of the parasite. 

None of the above symptoms, however, permits the diag- 



TAPE WORMS. 359 

nosis of tapeworm, for they are found also when it is not 
present. The diagnosis can be made only by the discov- 
ery of either segmeots of the parasite or their eggs in the 
stools. 

The tapeworm has a head or scolex, which may remain 
alive for years, — even when separated from the other part 
of the body, — an oblong neck and detachable segments 
(proglottides). The latter vary in size and in configura- 
tion the farther away from the head they are situated. 
They possess the power of moving. The tapeworm is a 
flat worm devoid of mouth or intestine. It grows by alter- 
nate generation through the germination of a pear-shaped 
primary host (head) and remains united with the latter for 
a considerable time as a long band-shaped colony. Each 
member of the colony forms a sexually active individual. 
The proglottides increase in size the more distant they are 
from the head. The tapeworm is an hermaphrodite. It is 
provided on its head with four sucking discs, by means of 
which it is enabled to attach itself to the intestinal mu- 
cosa. It derives its nourishment by means of pores from 
the intestinal chyme. The older proglottides contain a 
large number of fructified eggs. The latter are off and on 
emptied into the intestinal canal and then appear in the 
dejecta. 

The ovum contains an embryo which requires for its de- 
velopment an intermediary host. After reaching the stom- 
ach of the intermediary host the envelope of the ovum is 
dissolved by the gastric juice. The embryo is now set 
free and finds its way either by the lymphatics or by the 
blood-vessels to some place (usually the muscles) where it 
settles. Here it surrounds itself with a sac, which later 
on may become surrounded with a calcareous deposit. In 
this condition the embryo is called cysticercus or measle. 



360 



DISEASES OF THE INTESTINES. 



When the measle again reaches the stomach of a new host 
it then opens and its scolex advances into the small in- 
testine, where it develops into a full-grown taenia. 

Tcenia Solium. — Taenia solium, or the armed tapeworm, 
when fully developed, is from two to three metres long. 
Its head is of pinhead size and spherical in shape. It has 
four cuplike suckers, in the middle of which is situated the 
rostellum, the latter being surrounded with a large number 
of hooks (Fig. 44). These are arranged in two rows and 
number from twenty-four to twenty-six. Succeeding the 
head is a filiform neck, almost an inch long. Commencing 

at a certain distance from 
the head the body is di- 
vided into segments. 
The mature proglottides 




Fig. 44.— Head of Taenia Solium with Pro- 
truding Rostellum. Magnified 50 diameters. 
(Ziegler.) 



Fig. 45.— Half Developed and Fully 
Matured Segments. Natural size. 
(Leuckart.) 



are 1 to 1.5 cm. long and 6 mm. wide. The genital open- 
ing is situated at the side near the posterior border of the 
segment (Fig. 45). The uterus forms a straight median 
tube, giving off at right angles five to seven branches on 



TAENIA SAGINATA. 361 

«ach side. These branches are undivided at first, but to- 
ward the periphery ramify in the form of a tuft (Fig. 46) . 
The eggs are round and provided with a thick shell. 

Taenia solium inhabits the small intestine of human 
beings. The further development of the embryo into 



A 
Fig. 46.— Taenia Solium. Showing two proglottides. A, A, pores. (Huber.) 

measles occurs in the intermediary host, the pig, in which 
condition they reach the human system and are trans- 
formed into mature taenias. Rarely the measles (cysto- 
cercus cellulosse) are found in men, in which instance they 
occur in various organs, brain, eye, skin, etc. The grav- 
ity of the disease which they produce depends upon the 
importance of the organ they involve. 

Tmnia Saginata or Mediocanellata. — This tapeworm is 
the one most frequently observed in America as well as 
abroad. The taenia saginata is much longer, thicker, and 
wider than taenia solium. The head is 2.5 mm. large, has 
four large sucking-discs but no rostellum, and is often 
pigmented (Fig. 47) . The length of the worm is 4 to 5 
metres, the proglottides are unusually thick, the widest 
being in the middle. The mature segments occasionally 
attain a length of 2.5 cm. The uterus lies in the middle 
of the segment and gives off numerous branches on both 
sides (about twenty on each side (Fig. 48). The genital 
opening is situated on the side below the middle. The 



362 



DISEASES OF THE INTESTINES. 



eggs have an elliptical shape, a brownish color, and a con- 
tour exhibiting radiating streaks. 

The taenia saginata inhabits the small intestine of man. 
Its measles occur in beef, as has been demonstrated by 



// 



ff 



a 

^ 









\ 



Huber * and Leuckart. These measles are usually smaller 

than those of taenia solium. Human beings acquire this 

'Huber: "Twentieth Century Practice of Medicine," vol. viii., p. 



570, 



BOTHRIOCEPHALUS LATUS. 363 

taenia by the consumption of raw beef. The measles have 
not as yet been found in man. 

Bothriocephalus Latus, Tcenia Lata or Pig Head. — This 
tapeworm is the longest. It measures from five to eight 
metres. The head is elongated, of almond shape, being 
about 2.5 mm. in length (Fig. 49). It has two lengthy 
big grooves on its flat surface (Fig. 50) . The neck is nar- 
row, about 2 cm. long. The body is thin and flat like 
a ribbon, excepting the central part of the segments which 




Fig. 48.— The Uterus and its Branches in a Segment of Taenia Saginata. Enlarged 3 
diameters. CHuber.) 

project somewhat outward. The genital openings are on 
the flat surface in the middle, the female very close to the 
male. The uterus has a special opening and four to six 
visible uterine convolutions on each side, which look al- 
most like a rosette. The eggs are oval, round, with a thin 
membrane and a lid (Fig. 51). They measure 0.07 mm. 
in length and 0.04 in width. 

The measle of bothriocephalus latus occurs principally 
in fish, especially in pike, turbot, perch, and trout. 

The taenia lata lives in the small intestine of man, but 
is also, though rarely, found in dogs. In the northeast- 
ern part of Europe, Holland, Switzerland, and Japan this 
tapeworm is very prevalent. In America it occurs but in- 



364 



DISEASES OF THE INTESTINES. 



frequently. As stated above, among the symptoms pro- 
duced by bothriocephalus ansemia is often observed. 

Aside from the three tape- 
worms just described there exist 
a few more varieties which are 
only rarely met in human 
beings. They are : 

(1) Taenia Nana. — This is the 
smallest tapeworm found in 
man. It measures 10 to 15 mm. 
in length and may have one hun- 
dred and ninety segments. The 
head has four sucking - discs, 
a rostellum, • twenty - four to 
twenty-eight hooklets in a sin- 
gle row. The proglottides are 
short and broad; the genital 
openings are on one side. 
This tapeworm has been ob- 
served principally in Egypt and 
Italy in children. It usually 
occurs in large numbers in the 
small intestine, from forty to 
even five thousand. The symp- 

§jW toms produced by this tapeworm 
are mostly nervous disturbances, 
fainting spells, occasionally 
even epilepsy. 

(2) Toe n i a Cucumerhw. — 
This small cucumber-shaped 
tapeworm occurs frequently in 

the intestine of the dog, but has also been found, although 
rarely, in small children. The tapeworm is 10 to 40 cm. 




¥iG. 49. — Bothriocephalus Latus 
Natural size. (Leuckart.) 



TAPE WORMS. 



365 



long and about 3 mm. wide. The measle of this taenia 
inhabits the flea. 

(3) Tcenia Flavo-Punctata or Tcenia Diminuta. — This 
parasite is 2 to 6 cm. long and 3.5 mm. wide. Its head 
is very small, club-shaped, and provided with sucking- 
discs. The measle infests the caterpillar and cocoon of 






Fig. 50. 



Fig. 50.- 
FiG. 51.- 



FlG. 51. 
-Head of Bothrioeephalus Latus. Magnified. (Heller.) 
-Eggs of Bothrioeephalus. (Krabbe.) 



asopia famialis and in the coleoptera axispinosa. This 
tapeworm has been observed in man only a few times. 

(4) Bothrioceplialus Gordatus. — This tapeworm resembles 
in all particulars the bothrioeephalus latus except that it 
is much shorter and that the head merges into the proglot- 
tides directly without an intermediary neck. It occurs in 
the intestine of men and dogs in Greenland. 

The list of the tapeworms enumerated above is not com- 
plete, for there exist the taenia madagascariensis, bothrio- 
eephalus liguloides, and others, but as these .do not occur 
in Europe or America a description of them does not ap- 
pear to be of practical interest. 

Treatment. — Prophylaxis. In order to escape infection 
with tapeworm it is necessary to abstain from raw or me- 
dium done meats, including fish. The sanitary inspection 



366 DISEASES OF THE INTESTINES. 

of the meat is no absolute guarantee that it is free of 
measles. Thorough boiling or broiling of the meat de- 
stroys the cysticerci and thus the danger is avoided. In 
order to diminish the spread of tapeworm it is advisable 
to free the patient of the worms and thoroughly to destroy 
them as soon as possible after they have left the intestine. 
Whoever examines the proglottides or the ova should care- 
fully wash and disinfect his hands immediately afterward 
in order to avoid auto-infection. 

The direct treatment of the tapeworm consists in meas- 
ures to expel it from the intestinal canal. This is accom- 
plished by emptying the bowels previously and giving a 
vermifuge afterward. The treatment is carried out in the 
following way : For about two days before giving the ver- 
mifuge the patient is kept on a scanty diet, consisting cf 
some milk, meat and broth, very little bread or none at 
all. A laxative (calomel eight to ten grains or castor oil 
one tablespoonful) is given once a day. On the evening 
preceding the administration of the vermifuge the patient 
should have no supper or should take only salt herrings 
with onions. On the following morning a cup of coffee or 
tea is given. Half an hour to one hour later the vermifuge 
is administered. Among the drugs for the removal of the 
tapeworms the following are the most efficient : 

Male-fern extract is given in doses of 6 to 10 gm. ( 3 iss.- 
iiss.), as for instance: 

^ Extr. filicis mar. aether 8.0 ( 3 ij.) 

Syr. simpl. 40.0 ( % %) 

S. To be taken in ten minutes. 

The dose of male-fern should never be very high and 
should not exceed 10 gm. ( 3 iiss.), as symptoms of intoxi- 
cation have frequently been observed. 

Pomegranate root is also an efficient remedy, espe- 



TAPE WORMS. 367 

cially if it is fresh. It may be given in an infusion of the 
bark, three ounces of which are macerated in ten ounces of 
water and then reduced to one-half by evaporation. The 
entire quantity is then taken within half an hour. 

Pelletierine, the active principle of pomegranate root, 
may also be used in doses of five to eight grains. 

Flores koosso, about 20 to 30 gm. ( 3 v. to ?i.) of the 
blossoms are thoroughly mixed in sugar water or lemon- 
ade and should be taken within one-half or one hour, or — 

1$ Flores koosso, 

Mellis despumati aa 3 v. (20 gm.) 

Fiat electuariuni. S. To be taken in two portions. 

Kamala may also be employed in doses of 10 gm. 
( 3 iiss.) mixed in aqua fceniculi or in wine and taken in 
the same way. 

Turpentine 30 to 60 gm. ( 5 i.-ii.) may be given in cap- 
sules. After this medicament one or two glassfuls of milk 
should be taken. 

Pumpkin seeds (semina cucurbitae) may be administered 
in doses of 120 gm. ( §iv.), thoroughly mixed with the 
same amount of grape sugar. 

Cocoanut has also been recommended for this purpose. 
The milk and albumin of an entire nut should be consumed 
within one hour. 

Naphthalin in doses of 0.6 to 2.0 gm. (gr. x.-xxx.) may 
be given in capsules. 

Salol 3 gm. (gr. xlv.) in capsules may also be advanta- 
geously employed. 

One or two hours after the administration of the vermi- 
fuge a cathartic should be given, usually about two table- 
spoonfuls of castor oil, or citrate of magnesia one to two 
teaspoonfuls. The resulting evacuation must be thor- 



568 



DISEASES OF THE INTESTINES. 



oughly examined and the tapeworm looked f <r, especially 
its head. 

Children require a correspondingly smaller d se of the 
above remedies, according to their age. Patienl who are 
debilitated, or have intestinal disorders or organic lesions 
of the digestive tract, should not be subjected to this treat- 
ment, nor should it be employed shortly after typhoid 
fever or other grave diseases. In these conditions it is 
necessary to postpone the treatment until a more oppor- 
tune time. 

Trematodes (Fluke Worms). 

The trematodes are solid worms of a tongue or leaf 
shape. They possess a clinging apparatus in the form of 




Fig. 52.— Distoma Hepaticum, with Male and Female Sexual Apparatus. CLeuckart.) 
Magnified 2}4 diameters. 



oral and ventral sucking-cups varying in number. Some- 
times they are also provided with hook or clasp like pro- 
jections for this purpose. The intestinal canal is without 
any anus and is split like a fork nearly throughout its 
extent. The fluke worms are mostly hermaphroditic. To 
these belong : 

Distoma Hepaticum or Liver Fluke.— This parasite has 
a leaf shape, is 22 mm. long and 12 mm. wide. The ceph- 
alic end projects like a beak and bears a small cuplike 



DISTOMA LANCEOLATUM. 369 

sucker, ir winch the mouth is located. Close behind this 
on the ve oral surface is a second suction cup and between 
the two es the sexual orifice. The uterus consists of a 




Fig. 53.— Eggs of Distoma Hepaticum. (Leuckart.) Magnified 200 diameters. 

convoluted bulb-shaped bag situated behind the posterior 
sucker. On each side of the body lie the ovisacs and be- 
tween them the much branched testicular canals (see Fig. 
52). The eggs are oval, 0.13 mm. long and 0.08 mm. 
wide. They have a brownish color and are provided with 
a lid (Fig. 53). 

The liver fluke is rare in man, though frequently found 
in ruminating animals. It inhabits the biliary ducts and 
is occasionally found in the intestine and in the inferior 
vena cava. The symptoms which it produces are varied: 
jaundice, enlargement of the liver, diarrhoea, hemorrhages. 



Fig. 54.— Distoma Lanceolatum with its Inner Organs. (Leuckart.) Magnified 10 

diameters. 

Most probably the liver fluke reaches the intestinal canal 

by means of impure water or vegetables. 

Distoma lanceolatum is 8 to 9 mm. long and 2 to 2.5 mm. 

wide. It has a lancet shape and the head portion is not 

specially marked off from the body (Fig. 54). The eggs 
24 



370 



DISEASES OF THE INTESTINES. 



are considerably smaller than those of distoma hepaticum, 
being only 0.04 mm. long (Fig. 55). With regard to its 
occurrence and symptoms it resembles the liver fluke. 

Distoma haematobium or Bilharzia lwematobia is fre- 
quently found in hot climates, especially in Egypt. In 





Fig. 55.— Egg of Distoma Lanceolatum Shortly After the Formation of a Shell. (Leuck- 
art.) Magnified 400 diameters. 



the United States and in Europe it is very rarely found. 
This parasite has separate sexes. The male is from 12 
to 14 mm. long. Its body is smooth, but in its posterior 
portion rolled up into a tube, which serves for the recep- 
tion of the female (canalis gynsecophorus) (Figs. 56 and 
57). The female is from 16 to 19 mm. long and almost 





FIG. 56. 



Fig. 57, 



Fig. 56.— Distoma Haematobium. (Leuckart.) Male and female, the latter in the ca- 
nalis gynaecophorus of the former. Magnified 10 diameters. 
Fig. 57.— Eggs of Distoma Haematobium. (Leuckart.) a, Egg with terminal spine ; 5, 
egg with lateral spine. Magnified 150 diameters. 

cylindrical. The sexual opening lies in both sexes close 
behind the ventral sucker. The distoma haematobium 



ROUND WORMS. 371 

finds its way into the intestinal canal of man and then 
reaches the portal circulation, where it develops. In the 
intestinal canal it has been encountered very rarely, in 
which case ulcerations of the intestinal mucosa were pres- 
ent. It frequently causes hematuria and great cachexia, 
terminating fatally in some instances. 

As regards treatment, the removal of these fluke worms 
must be undertaken in identically the same manner as that 
of the tapeworms described above. 

Nematodes {Round Worms). 

The round worms which occur as parasites have a slen- 
der, cylindrical, sometimes filiform body, with neither 
segments nor appendages. The integument is thick and 
elastic. The oral opening is at one extremity and provided 
with either soft or hornlike lips. The alimentary canal 
extends throughout the entire body cavity, terminating in 
an opening upon the ventral side at a short distance from 
the posterior extremity. The sexual organs and their ori- 
fices lie on the ventral surface. The female aperture is 
located at about the middle of the body ; in the male the 
sexual orifice is situated close to the anus. The males 
are usually much smaller than the females. 

Asca?*is Lumbricoides (Common Spool or Bound Worm). — 
This worm is one of the most frequently observed para- 
sites in man. The round worm has a light brown or red- 
dish color and a cylindrical shape. The male is 20 cm. 
and the female 30 cm. long. The posterior extremity of 
the male is bent in the form of a hook and provided with 
two spicules or chitinous processes. The mouth is sur- 
rounded by three muscular lips provided with very fine 
teeth. The sexual openiug of the female lies anterior to 
the middle of the body (Fig. 58). The eggs when ripe 



372 



DISEASES OF THE INTESTINES. 




Fig. 58.— Ascaris Lumbricoides. (Perls.) 
A, Female ; J5, male. (Natural size.) 
At a Is the female sexual orifice ; c, 
the two spicules of the male ; b, head 
extremity (magnified) of the worm, 
with the three lips. 



have a double shell and 
around this is an albumi- 
nous envelope which is ir- 
regularly shaped, and 
studded with excrescences 
(Fig. 59). The long di- 
ameter of the egg is about 
0.05 mm. 

The round worm pos- 
sesses a strong odoriferous 
principle which is very 
perceptible even after the 
worm has been carefully 
washed. According t o 
Huber, ' this substance 
may occasion urticaria in 
persons predisposed to this 
eruption. It is not im- 
probable that certain of 
the symptoms of ascariasis 
are due to the action of 
the same element. 

The principal habitat of 
ascaris lumbricoides is the 
small intestine of man. It 
develops here often in large 
numbers, fifty to one hun- 
dred and more occurring 
together. The mode of 
transmission, according to 

1 Huber : " Twentieth Century 
Practice of Medicine, " vol. viii., 

p. 583. 



ASCARIS LUMBRICOIDES. 




Leuckart, Grassi, 1 and Lutz, 2 is by ingestion of the eggs of 
the ascaris, there being no intermediate host. The full 
development of the round worm from the egg to its period 
of sexual maturity requires ten to twelve weeks. Infection 
usually takes place by eggs existing in the soil near dwell- 
ing-places, in the drinking-water, and 
also in some foods, principally salads 
and fruits. Ascaris lumbricoides is 
most frequently found in children three 
to twelve years old, the poorer classes 
showing a larger percentage than the 
well-to-do. In grown persons the worm 
is not so frequent. The female sex is 
more frequently infected than the 
male. 

The diagnosis of ascariasis is made 
by the detection of the worm in the fecal matter, or of its 
eggs, which are easily recognized. 

Symptoms. — Ascariasis may exist without giving rise to 
any symptoms whatever. Occasionally, however, there are 
various disturbances : anorexia, nausea, irregularity of the 
bowel, meteorism, an irregular pulse; in children black 
rings around the eyes, much nervousness, even convul- 
sions. In rare instances progressive ansemia has been ob- 
served (Leichtenstern). Anatomically hyperreraia of the 
intestinal wall has been frequently found, erosions are rare. 
Itching of the nose is often present in ascariasis and may 
be due to the odoriferous principle. 

The round-worm is liable to wander and may then give 
rise to severe complications. In several instances it has 



Fig. 59.— Egg of As- 
caris Lumbricoides 
(.Leuckart) with Shell 
and Albuminous En- 
v e 1 o p e . Magnified 
300 diameters. 



1 Grassi : Centralbl. f . Bacteriologie und Parasitenkuncle, 1887. 

2 Adolf Lutz: "Klinisches uber Parasiten des Mensclien und der 
Hausthiere." Centralbl. f. Bacteriologie, 1889. 



o<4 DISEASES OF THE INTESTINES. 

been found in the bile duct, in the gall bladder, and even 
in the liver, producing abscesses and even a fatal issue. 
The worm occasionally migrates into the stomach and pro- 
duces pain and often vomiting. In the latter act it is often 
expelled from the mouth. Occasionally it ascends the 
oesophagus and enters the larynx, causing asphyxia, and, 
in rare instances, even death. It has also been found in 
hernial sacs and in the peritoneal cavity, but it is gen- 
erally believed that it cannot penetrate through the 
healthy intestinal wall. Obstruction of the bowels by a 
conglomeration of ascarides has also been thought pos- 
sible ; its real occurrence, however, is denied by Leichten- 
stern. ' 

Prophylaxis requires total destruction of all the eggs of 
the ascaris passed with the fecal matter of the patient. 
The grounds near dwellings should be kept perfectly clean 
and the hands should be frequently washed. All foods 
should be protected against a possible infection. 

Treatment. — The treatment consists in freeing the pa- 
tient from the worms. This is done in a similar manner 
as in the case of tapeworms. The intestinal tract is kept 
partially empty for a day or two before the administration of 
the anthelmintic. The most efficient remedy for this pur- 
pose is santonin, which is given in a dose of 0.02 to 0.06 
gm. (gr. ir-i.) twice or four times a day. Then a purgative 
remedy is given. Some combine the santonin with the 
purgative and give them together. Thus santonin 0.2 (gr. 
iiiss.), castor oil 60 gm. ( 3 ii.), twice or three times daily 
one teaspoonful for small children, a dessertspoonful for 
larger children, and one tablespoonful for grown people. 

1 Leichtenstern : " Verengerimgen, Verschliessungen und Lageveran- 
derungen des Darms." von Ziemssen's Handbuch der spec. Path, und 
Therapie, Bd. vii., Abth. 2. 



OXYURIS VERMICULARIS. 375 

The santonin may also be given in combination with cal- 
omel; thus — 

$ Calomel 0.05 to 0.1 (gr. i.-ij.) 

Santonin 0.02 (gr. £) 

T. d. No. ix. S. One powder three times daily. 

Flores cinae, the plant from which santonin is obtained, 
may also be administered in doses of 0.5 to 2 gm. as 
powders or as an electuary, with the addition of jalap, 0.1 
to 0.2 gm. 

Chenopodium or wormseed is also a popular remedy, 
the powdered seeds being given in doses of 1 to 2 gm. 
(gr. xv. -xxx.), or the volatile oil in five to ten drop doses. 
Thymol has also been recommended in doses of 0.5 to 
2 gm. (gr. vii.-xxx. ) in twenty-four hours. It may be given 
in gelatin capsules. Irrigation of the bowels with water 
to which three to five drops of benzene have been added 
has likewise been suggested, but does not appear as bene- 
ficial as santonin. 

Ascaris Mystax.—K round-worm resembling ascaris lum- 
bricoides but much smaller and somewhat thinner. This 
parasite frequently occurs in animals, principally in cats, 
but has been discovered very rarely in man. No symp- 
toms whatever have been observed. 

Oxyuris Vermicular is, Aidtail, Seat or Pin Worm, Mag- 
got or Thread Worm. — This parasite is white and filiform, 
4 to 12 mm. long and 0.2 to 0.6 mm. thick (Fig. 60). The 
males are much smaller than the females. The oxyuris 
has three small knoblike lips. The female possesses two 
uteri passing backward and forward from the end of the 
vagina. The opening of the latter is situated above the 
middle of the body. The eggs are 0.05 mm. long and 0.02 
wide. The contents are granular and the shell appears 
white. 



376 



DISEASES OF THE INTESTINES. 



Infection takes place when the eggs of oxyuris reach the. 
stomach. Here the shell opens and the embryo migrates 

into the small intestine 
(Fig. 61). After fructi-. 
flcation has taken place 
the females usually begin 
to wander along the in- 
testinal canal. In the 
caecum they generally 
make quite a long sojourn 
until the eggs are almost 
ripe. Then they again 
begin to pass down- 
ward. According t o 
Leichtenstern, Lutz, and 
Huber, the females do not 
pass their eggs within 
the intestinal canal. As 
a rule they first leave the 
For this reason the fecal 




Fig. 60.— Oxyuris Vermicularis : <x, natural 
size ; b, head ; c, tail, magnified ; d, head 
greatly magnified. 



bowel and then deposit the eggs. 

matter usually does not contain any eggs. 

The symptoms which are most frequently observed con- 
sist in pronounced pruritus ani due to the irritation pro- 
duced by the passing of the parasites out from the rectum. 
Frequently the itching annoys the patient as soon as he 
retires. Various nervous symptoms are occasionally ob- 
served: anorexia, nausea, dizziness, palpitation of the 
heart, pollutions and spermatorrhoea in the male; besides 
diarrhoea occasionally occurs. Pronounced anaemia is en- 
countered, although rarely. In rare instances the para- 
sites reach the vagina and cause irritation there. Nymph- 
omania has then been observed. 

Infection probably occurs through direct conveyance of 



OXYURIS VERMICULARIS. on 

the eggs by the unwashed hands of the host. It is also 
possible that ova dried by the sun exist on fruit, radishes, 
or salads, in which state they may be carried into the 
stomach. 

The diagnosis of the thread worm is made by inspection 
of the anal region and by the rinding of the oxyuris. 

With regard to prophylaxis extreme cleanliness is of the 
greatest importance. Fruits should be thoroughly cleaned 
and then peeled before they are eaten. The eating uten- 
sils of a person infected with oxyuris should never be used 
by another, unless they have been thoroughly disinfected. 
The same applies to the clothes. Sleeping with an infected 
person should be forbidden, and even touching his hands 






Eig. 61.— Development of Oxyuris Vermicular is. (Heller.) a-e, Segmentation of the 
yolk ; /, ovum containing tadpole-shaped embryo, seen from the side ; g< abdominal 
view of the same ; 7?, ovum with worm-shaped embryo ; i, embryo escaping from the 
shell ; li, free embryo capable of motion. 

requires immediate washing, as otherwise infection may 
take place. 

Treatment. — Santonin is the principal remedy for com- 
bating oxyuriasis. It is given in the same way as de- 



378 DISEASES OF THE INTESTINES. 

scribed in the treatment of ascaris lumbricoides. Here, 
however, irrigations of the bowel with water and the addi- 
tion of a few drops of benzene or thymol or vinegar (three 
to four tablespoonsful to a quart), or of sapo medicatus in 
a one-half to one-per-cent solution may be advantageously 
used. The anal region should be thoroughly cleansed. 
If the pruritus ani is quite intense, application to the anal 
region and rectum of unguentum hydrarg. cinerei or the 
use of a suppository of ung. hydrarg. cinerei 1 gm., in 
cacao butter 2 gm. will afford relief. 

Ancliylostoma Duodenale. Dochmius Duodenalis, Unci- 
naria Duodenalis, or Strongylus Duodenalis. — This impor- 
tant parasite was first described by Dubini 1 in 1838. 
Bilharz 2 and Griesinger 3 recognized this parasite as the 
cause of the Egyptian chlorosis. Some time afterward 
the anchylostoma was observed in severe cases of anaemia 
among workmen in tunnels and brickmakers. 

The anchylostoma duodenale is cylindrical in shape, 0.5 
to 1 mm. thick and 6 to 18 mm. long. It is yellowish or 
grayish-white in color, with translucent edges. The male 
is much shorter than the female. The cephalic end is 
curved toward the dorsal surface and is provided with an 
oral capsule at the margin of which there are six hooklike 
teeth. Further within the capsule there are three sharp 
chitinous processes (Figs. 62 and 63). The male is more 
slender and transparent than the female. Its head end is 
bent backward. The tail end appears somewhat swollen, 
containing the bursa copulatrix, and is much more curved 
than the head. In the female the caudal end is pointed 
and armed with an awl-like prong ; the genital opening 

1 Angelo Dubini: Gaz. med. Lombard., 1843. 

2 Bilharz: Wiener med. Wochenschr., 1856. 

3 Griesinger: Arch. f. physiolog. Heilkunde, 1854. 



ANCHYLOSTOMA DUODENALE. 



379 





Fig. 63.— Cephalic End of Anchylostoma Duo- 
denale. (Schultheiss.) a, Mouth-capsule ; 
b, teeth of ventral border ; c, teeth of dorsal 
border; d, buccal cavity: e, skin-sac on 
ventral side of head ; /, muscular layer ; g, 
dorsal groove ; 7i, oesophagus. 




Fig. 64.— Eggs of Anchylostoma Duodenale. 
(Perroncito and .Schultheiss.) a, b, c, d, 
Different stages of cleavage ; e, /, eggs with 
embryos. Magnified 200 diameters. 




Fig. 62.— Male of Anchylostoma Duodenale. (Schultheiss.) a, Head with mouth-cap- 
sule ; Z>, oesophagus ; c, intestine ; d, anal glands ; e, cervical glands ; /, skin ; g, 
muscular layer ; 7i, porus excretorius ; i, triple bursa ; 7c, ribs of the bursa ; 7, testicu- 
lar canal ; m, vesicula seminalis ; n, ductus ejaculatorius ; o, groove of latter ; p, 
penis ; q, sheath of penis. Magnified 20 diameters. 



380 DISEASES OF THE INTESTINES. 

lies behind the centre of the body. The eggs are oval, 
0.06 mm. in length and 0.03 mm. in width (Fig. 64). 

The habitat of the anchylostoma is the duodenum, the 
jejunum, and the upper part of the ileum. Here the worm 
attaches itself to the intestinal mucosa and feeds by suck- 
ing the blood of his host. According to Leichtenstern, * 
active migration of the worm begins at the time of the first 
copulation in the fifth week. Young worms change their 
place quite frequently and hence give rise to repeated hem- 
orrhages. Colic, and acute anaemia are encountered at an 
early period after infection. 

Under favorable conditions the eggs develop outside of 
the body into rhabditis-like larvae, becoming enclosed in 
a protecting envelope or encysted. In this stage the larvae 
may be carried along with the dust and contaminate fruit 
and water. On reaching the small intestine they develop 
into mature worms. This parasite is always encountered 
in great numbers if present in the intestines. Leichten- 
stern never found them in a smaller number than one 
hundred, but sometimes their total reached three thou- 
sand. 

The symptoms produced by anchylostoma consist of gas- 
tralgia, nausea, occasionally vomiting, constipation, rarely 
diarrhoea, and severe anaemia, the latter becoming progres- 
sively worse. The patient with anchylostoma does not 
greatly emaciate, but becomes pale, extremely weak, and 
suffers from dizziness and shortness of breath after the 
slightest exertion. His extremities are cold, slight hemor- 
rhages occur frequently, and oedema of the ankles devel- 
ops. A systolic murmur may be heard at the apex of the 
heart, the pulse is accelerated, and fever may be present 

1 Leichtenstern : Centralbl. f . klin. Medicin, 1885, and Deutsche med. 
Wochenschr., 1885, 1886, 1887. 



ANCHYLOSTOMA DUODENALE. 381 

toward evening. An inclination to eat earth (geophagia) 
is not rarely observed. 

The dejecta are of a brownish color, although admixture 
of blood cannot be recognized macroscopically. Micro- 
scopically Charcot-Ley den's crystals, as well as the eggs 
of the parasites, are often found in the stools. The urine 
rarely contains albumin, but frequently indican. The con- 
dition of the blood resembles that found in pernicious 
anaemia : enormous decrease of the red blood corpuscles, 
poikilocytosis, nucleated red blood corpuscles, and a slight 
increase of the leukocytes, especially of the eosinophile 
cells. 

Anatomically the mucosa of the small intestine is found 
greatly congested and ecchymoses are visible here and 
there. Peyer's patches and the solitary follicles are often 
swollen. The heart is found hypertrophied and dilated, 
the liver and spleen may be diminished in size, normal, or 
in an amyloid condition. The same can be said of the 
kidneys. There is no doubt that the principal deleterious 
action of the anchylostoma consists in the profuse loss of 
blood caused by the parasites. Whether some toxic sub- 
stances generated by them participate in producing the 
grave symptoms is questionable. 

The course of the disease is protracted and its severity 
depends greatly upon the number of parasites present. If 
the latter is great, the disease may progress quickly and 
the patient succumb with the symptoms of general dropsy, 
dyspncea, and heart failure or pulmonary oedema. If the 
number of the parasites is small, the patient may live 
many years and ultimately recover entirely. Recovery is 
also possible by successful expulsion of the parasites from 
the intestinal tract. 

The diagnosis of anchylostomiasis is made by the pres- 



382 



DISEASES OF THE INTESTINES. 



ence of the symptoms of anaemia in conjunction with the 
discovery of the anchylostoma eggs in the dejecta. 

With regard to prophylaxis the 
above given rules for the prevention of 
the round- and thread-worms are also 
applicable here. Extreme cleanliness 
of the body and of the food is of 
greatest importance. 

The treatment consists in the ad- 
ministration of extract of male-fern, 
which should be employed in the 
same manner as described above for 
the tapeworm disease. 

Anguillula Stercoralis. — This nema- 
tode is 0.8 to 1.2 mm. long, the male 
shorter than the female (Fig. 65). 
The male is indigenous in Cochin 
China and Italy. In the latter coun- 
try it often occurs simultaneously with 
anchylostoma. If the worms exist in 
large numbers they may produce patho- 
logical conditions. According to Golgi 
and Monti, 1 the anguillula stercoralis 
penetrates into Lieberkuehn's crypts 
and there deposits its eggs and young. 
Anguillula intestinalis, which is 2.25 
mm. long, belongs to the same variety 
as anguillula stercoralis and is found 
under the same conditions. Only the female of this worm 
is known. The eggs develop in the intestinal canal and 
exhibit only the first stages of segmentation at the time 
of their passage with the faeces. 

1 Golgi e Monti : Arch, per le science med. , 1886, No. 3. 



Tig. 65.— Female of An- 
g u i 1 1 u 1 a Stercoralis, 
with Eggs and Embryos. 
(Perroncito.) Magni- 
fied 85 diameters. 



TRICHOCEPHALUS DISPAR oSd 

Trichocephalus Dispar. Whip- Worm. — This parasite is 
quite common, but comparatively harmless. Its habitat 
is the caecum and the neighboring section of the intestine. 
It lives upon blood which it abstracts from the intestinal 
mucosa. This parasite is 4-5 cm. long, the male being 
smaller than the female. The head end, which is about 
three-fifths of the entire length, is drawn out into a fine 
thread; the tail end is not so thin, being up to 1 mm. in 
thickness (Fig. 66). The male has a spiral body from the 
end of which the spicule projects. The body of the fe- 
male is straight and terminates in a blunt extremity. The 





Fig. 66.— Trichocephalus Dispar. (Heller.) a. Fig. 67.— Ova of Trichocephalus 
Female . b, male. Natural size. Dispar in Process of Develop- 

ment. (Huber.) 

ova are almost lemon-shaped, dark brown in color, 0.05 
mm. in diameter (Fig. 67). The number of eggs in a sin- 
gle female was estimated by Leuckart at 58,000. They are 
hatched out very slowly. 

Leuckart asserts that the dispersion of the eggs and con- 
sequent spread of infection may readily occur through 
wind, rain, or dust, and that the eggs may be ingested with 
fruit and salads. The number of these worms found in 
one patient is usually small, from six to twenty. 

The symptoms are but very slight, occasionally diarrhoea 
exists, sometimes there are some reflex nervous conditions. 

The diagnosis can usually be easily made from the shape 
of the ova. The passage of the living worms in the stools 
occurs but rarely. 



384 



DISEASES OF THE INTESTINES. 




Plate I.— Trichina Spiralis (Huber). 



TRICHINA SPIRALIS. 385 

With regard to treatment Lutz recommends the admin- 
istration of thymol ; Hosier l and Peiper 2 employ rectal 
irrigation of water, to which a few drops of benzene have 
been added. Extract of male-fern may also be used inter- 
nally. 

Trichina Spiralis. — The trichina spiralis was discovered 
by Paget, 3 but its pathological importance was first recog- 
nized by Zenker. 4 This parasite is observed in two forms, 
the trichina of the intestine and the trichina of the muscles 
(see Plate I.). 

The trichina reaches the stomach through the ingestion 
of pork containing encapsulated trichinae. In the stomach 
the capsule opens about three to four hours after the inges- 

1 Hosier: " Darminf usion. " Real-Encyclopadie der gesarnmten Heil- 
kunde, Bd. v. 

2 Peiper: " Helminthen. " Real-Encyclopadie der gesammten Heil- 
kunde, Bd. ix. 

3 Paget, cited after Huber: "Twentieth Century Practice of Medi- 
cine, " vol. viii., p. 608. 

4 Zenker: Deutsches Arch, fur klin. Medicin, i., 1866. 



Explanation of Plate I. 

Fig. 1.— Muscle Trichina Enclosed in a Fully Developed Cyst. X 240. Cy, cyst; Bg* 
connective-tissue envelope ; Fk, fat globules. 

Fig. 2.— The Same Removed from the Cyst. X 400. Oe, (Esophagus ; Zk, cell 
bodies ; L, side lines ; Oi\ ovary ; Ch.D, chyle duct. 

Fig. 3.— Part of the Ovary, x 600. Is readily distinguished from the testicle by the 
varying size of the germ cells. 

Fig. 4.— Male Intestinal Trichina. X 100. T, Testicle ; d ej, ejaculatory duct ; Zk, 
cell bodies. 

Fig. 5.— Female Intestinal Trichina. X 90. Ov, ovary ; E, embryos ; Oe, genital 
opening from which the embryos escape. 

Fig. 6— Free Embryo. X 400. O, mouth ; A, anus. 

Fig. 7.— Embryo About Three Days After Having Entered the Muscle Fibre. J£F, 
normal muscle fibre. 

Fig. 8— Muscle Trichina, About Six Days Old, in the Greatly Swollen Sarcolemma 
Sheath Traversed by Capillary Vessels, Cap. 

Fig. 9.— Muscle Trichina, Four Weeks Old, Enclosed in a Capsule, Cy A, within the 
sarcolemma sheath, Sk ; Bk, connective-tissue capsule in process of active growth ; ft, 
nuclei ; MF. contents of the sarcolemma sheath at each pole of the capsule. 

Fig. 10.— Muscle Trichina with Calcified Capsule. Fk, Fat globules. 
25 



386 DISEASES OF THE INTESTINES. 

tion of the meat and the embryos rapidly develop. At the 
end of thirty to forty hours fructification of the young par- 
asites takes place. 

The intestinal trichinae are visible with the naked eye, 
the females being 3 to 4 mm. long and the males half this 
size. The caudal extremity is thicker than the head end. 
Five days after fecundation the females give birth to living 
young ones. The young brood wanders directly from the 
intestine of the host into his muscles. Here they further 
develop. In this condition they give rise to a febrile dis- 
ease accompanied by severe muscular symptoms which 
may lead to death. Sometimes the trichinae become en- 
capsulated. The symptoms vary according to the number 
of worms which have been ingested. Gastro-intestinal dis- 
turbances usually appear on the second or third day after 
the ingestion of the contaminated meat. Vomiting, diar- 
rhoea, colic often appear. 

The disease known as trichinosis, which depends upon 
the further development of the young embryos in the mus- 
cles of the host, is not within the scope of this book, and 
we refer to this parasite only as far as its occurrence in 
the intestines is concerned. With regard to prophylaxis 
pork should never be eaten raw. The treatment after the 
ingestion of trichinous meat consists in the employment of 
lavage of the stomach, if the physician is called early enough 
after the meal. In addition a vermifuge and cathartic rem- 
edy should be given immediately. 



INDEX. 



Abel ma xx. 22 

Absorption as a function of the 

bowel. 24 
Acholic stool. 58 
Adenoma of the intestines. 173 
^Egineta. Paulus. 341 
Albumin in the faces. 53 
Albuminates, putrefaction of. in 

the large intestine. 21 
Alimentation, rectal. s 

subcutaneous, S|1 
Allingbam. 87. ITS. 191, 194 
Allingham's rectal speculum. 3T 
Amoeba, 355 
Amoebic dysentery, 113 
Amyloid ulcers. 145 
Anacker. 317 

Anaesthesia <»f the intestine. 339 
of the rectum. 339 
treatment. 340 
Anatomy of the intestine. 1 
Anchylostoma duodenale, 37 v 
course. 381 
diagnosis.. 3 s 1 
prophylaxis. 382 
symptom-. 380 
treatment. 382 
Angioma of the intestines. 173 
Anguillula intestinalis. 382 

stercorals. 3S2 
Antiperistalsis of the intestine. 30 
Anus, anatomy of the. 16 

fissure of the, 199 
Appendicitis. 202 
catarrhal. 208 
definition, 202 



Appendicitis, diagnosis. 220 

differential diagnosis. 231 

etiology, 203 

general remarks. 202 

indications for operation.. 231 

larvata of Ewald, 215 

morbid anatomy. 2 - 

perforativa. 210 

prognosis. 222 

severe form 210 

symptomatology. 212 

synonyms. 202 

treatment. 224 

ulcerosa et gangrenosa, 210 
Appendicular inflammation. 202 
Appendix vermiformis. 13 
Aretieus. 113 
Ascariasis. diagnosis. 373 

prophylaxis. 374 

symptoms. 373 

treatment. 374 
Ascaris lumbricoides. 371 

mystax. 375 
Atony of the bowel. 297 
Auscultation, 45 
Awl-tail. 375 



Balaxtldioi coli. 
Bamberger. 206 
Barbacci. 206 
Barthelemy. 117 
Basch, 55 
Bauhin's valve. 13 
Bayle. 147 
Beauchef. 114 
Beck. Carl. 204. 22- 



388 



INDEX. 



Benign tumors of the intestines, 

173 
Bernard, Claude, 19 
Bienstock, 77 

Bile pigment in the fseces, 57 
Bilharz, 378 

Bilharzia haematobia, 370 
Biliary acids in the fasces, 57 
Birch-Hirschfeld, 149 
Blood in the faeces, 56 
Boas, J., 42, 48, 93, 218, 220, 225, 

226, 227, 230, 345 
Bonnecken, 254 
Borborygmi, 45 
Bothriocephalus cordatus, 365 

latus, 363 
Bouchard, 102, 304 
Boudet, 84, 260, 315 
Bougies, rectal, 43 
Bowel, atony of the, 297 
Brahm-Houkgeest, 28, 289 
Brinton, 260. 
Brooks, Le Roy J., 273 
Brunner's glands, 9 
Brunton, 330 
Bryant, J. D., 13, 157 
Bull, W. T., 203, 229 
Bunge, 59 

Cmcum, anatomy of the, 12 
Cahn, 267 

Cancer of the duodenum, symp- 
toms, 165 
of the intestine, 156 
course, 169 
definition, 156 
diagnosis, 169 
etiology, 156 
location, 157 
morbid anatomy, 158 
prognosis, 170 
symptomatology, 160 
treatment, 170 
of the large bowel, symptoms, 
166 



Cancer of the rectum, symptoms,, 
167 

of the small intestines, symp- 
toms, 166 
Carbohydrates in the fseces, 54 
Carbolic acid injections in hemor- 
rhoids, 292 
Cash, 330 
Catarrh, acute intestinal, 86 

chronic, of the bowels, 97 
Cauterization in hemorrhoids, 292 
Celsus, 113 

Cercomonas intestinalis, 356 
Cestodes, 357 
Charcot, 292 
Chlapowski, 40 
Cholera nostras, 86 
Clapotage, 42 
Clark, Alonzo, 226, 308 
Colic, intestinal, 332 

mucous, 341 
Colitis, acute, 93 
Colon, anatomy of the, 11 

ascending, 14 

descending, 15 

transverse, 14 
Compression of the intestine, 23£ 
Concretions in the faeces, 59 
Constipation, 297 

definition, 297 

dependent upon other dis- 
eases, 302 

diagnosis, 308 

etiology, 298 

habitual, 297 

prognosis, 310 

prophylaxis, 310 

symptomatology, 303 

synonyms, 297 

treatment, 310 
dietetic, 311 
mechanical, 312- 
moral, 311 
Cooper, 293 
Cooper-Forster, 161 



INDEX. 



389 



Cornil, 348 

Councilman, 116, 119, 122 
Crede, 285 

Crushing in the treatment of hem- 
orrhoids, 194 
Cruveilhier, 177, 343 
Curschmann, 264, 270 
■Cysts of the intestines, 173 

Da Costa, 343, 344, 350 
Damsch, 46 
Dastre, 19 
Deaver, 228 
Demant, 288 
Delafield, F., 104 
Diarrhoea, 290 

acute, 86 

diagnosis, 295 

dyspeptic, 293 

etiology, 290, 294 

membranous, 341 

morning, 104 

nervous, 290 

prognosis, 295 

stercoral, 294 

symptomatology, 290, 294 

treatment, 295 

tubular, 341 
Diet, 77 
Dilatation of the sphincters in the 

treatment of hemorrhoids, 191 
Distoma haematobium, 370 

hepaticum, 368 

lanceolatum, 369 
Dochmius duodenalis, 378 
Douglas' fold, 15 
Doumer, 315 
Dubini, 378 
Dunin, 300 
Duodenal ulcer, 133 
course, 138 
defiuition, 133 
diagnosis, 138 
etiology, 133 
morbid anatomy, 134 



Duodenal ulcer, prognosis, 139 
symptomatology, 136 
synonyms, 133 
treatment, 139 
Duodenitis, acute, 92 
Duodenum, anatomy of the, 1 
Dutrouleau, 125 
Dynamic ileus, 263 
Dysentery, 113 

amoebic, 113 

bacillary theory of, 117 

complications, 127 

course, 127 

definition, 113 

diagnosis, 129 

etiology, 113 

morbid anatomy, 118 

prognosis, 129 

serumtherapy of, 130 

symptomatology, 123 

synonyms, 113 

treatment, 129 
Dyspeptic diarrhoea, 293 

Edebohls, 204, 213, 214 

Edwards, 344 

Ehrlich, 344, 348 

Ehrmann, 31 

Eichberg, 116 

Eichhorst, 136 

Eisenlohr, 144 

Electricity in intestinal obstruc- 
tion, 269 
in the treatment of constipa- 
tion, 314 
in the treatment of disease, 84 

Elsberg, C. A., 73 

Embolic ulcers, 140 

Embolus of the arteria mesaraica 
superior, 141 
of the inferior mesaraic artery, 
144 

Endo-appendicitis, 209 

Enemata in the treatment of con- 
stipation, 316 



390 



INDEX. 



Enteralgia, 332 

definition, 332 

diagnosis, 335 

etiology, 332 

prognosis, 336 

symptomatology, 333 

synonyms, 332 

treatment, 336 
Enteritis, acute, 86 

chronic, 97 

crouposa, 113 

membranous, 341 

necrotica, 113 
Enterospasmus, 301 
Erdmann, John F., 273 
Escherich, 76, 206 
Esmarch, 195 
Ewaid, C. A., 65, 99, 136, 215, 225, 

226, 230, 345, 346 
Examination, methods of, 32 
Extirpation of hemorrhoids, 195 

Faeces, abnormal admixtures in 

the, 51 
albumin in the, 53 
bile pigment in the, 57 
biliary acids in the, 57 
blood in the, 56 
carbohydrates in the, 54 
chemical examination of the, 

52 
concretions in the, 59 
examination of the, 49 
fat in the, 55 
ferments in the, 59 
fragments of tumor in the, 51 
micro-organisms in the, 74 
microscopical examination of 

the, 65 
mucin in the, 53 
odor, 50 

peptone in the, 54 
propeptone in the, 54 
pus in the, 51 
reaction of the, 52 



Faeces, remnants of food in the, 51 
Fat in the fasces, 55 
Fecal accumulation as a cause of 
chronic obstruction, 276 

fever, 308 

tumors complicating consti- 
pation, 306 
Ferguson, E. D., 239, 273 
Fermentation test, Schmidt's, 55 
Ferments in the faeces, 59 

of the pancreas, 19 
Fever, fecal, 308 
Fibroma of the intestines, 173 
Finger cot, 42 
Fischel, 292 
Fischl, 92 

Fissure of the anus, 199 
Fitz, Reginald, 117, 203, 228, 264 
Flatau, 318 
Flatulency, 327 
Fleiner, 82, 268, 317, 352 
Fleischer, 59, 220, 288 
Flexner, 118 
Fluke worms, 368 
Foreign bodies, obturation by, 240* 
Fowler, 203, 205, 206, 208, 220, 

228 
Frentzel, 271 
Frerichs, 147 
Friedenwald, J., 43 
Furbringer, 271 

Gall stones, obturation by, 239 

Galvano-cautery in the treatment 
of hemorrhoids, 194 

Gerhard t, 142 

Gerry, 117 

Gersuny, 41 

Gibson, C. L., 272 

Glycerin injections in the treat- 
ment of constipation, 317 

Golgi, 382 

Good, Mason, 342 

Gouley, J. W., 273 

Graser, 195, 265, 270, 271 



INDEX. 



391 



Grasse, 373 

Graves, 226 

Grawitz, 144 

Griesinger, 378 

Grisolle, 202, 203, 226 

Guttmann, P., 210 

Gymnastic exercises in the treat- 
ment of constipation, 314 
exercises in the treatment of 
disease, 83 

Habershon, 82, 306 
Habitual constipation, 297 
Hackel, 315 
Haguenot, 247 
Hall, Marshall, 90 
Hammarsten, 26 
Harris, 116, 118, 119, 132 
Haustra cob. 12 
Hawkes. F.. 229 
Hegar, 144 
Hemorrhoids, 175 

complications, 195 

definition. 175 

diagnosis, 185 

etiology, 175 

morbid anatomy, 177 

prognosis, 186 

symptomatology, 180 

synonyms, 175 

treatment, 186 
radical, 191 
Henrot, 320 
Heryng, 39 
Heusgen, 161 
Hippocrates, 113 
Hirschler, 22 
Hlava, 116 
Hodenpyl, 206 
Hoffmann, 271 
Houston, 192 
Hoyer, 344 
Huber, 362, 372, 376 
Hydrocephaloid, acute, 90 
Hydrotherapy, 83 



Hydrotherapy in the treatment of 

constipation, 315 
Hyperaesthesia of the intestine, 339 
Hypogastric neuralgia, 338 
treatment, 338 

Ileocecal valve, 13 
Ileum, anatomy of the, 4 
Ileus, 233 

dynamic, 263 
Illoway, 313 
Incarceration, acute, 261 
Inflation of the bowel with air in 
intestinal obstruction, 268 
of the intestine, 45 
Infusoria, 356 
Injection of water per anum for 

examination, 48 
Injections as a method of treat- 
ment. 81 
in the treatment of constipa- 
tion, 316 
Inspection, 34 
Interrogation. 32 
Intestinal catarrh, acute. 86 
definition, 86 
diagnosis. 94 
duration, 93 
etiology, 86 
localization, 92 
morbid anatomy, 88 
prognosis. 94 
symptomatology, 89 
synonyms, 86 
treatment, 94 
catarrh, chronic, 97 
course, 106 
definition, 97 
diagnosis, 106 - 
etiolog)? - , 97 
morbid anatomy, 98 
symptomatology, 101 
synonyms, 97 
treatment, 108 
colic, 332 



392 



INDEX. 



Intestinal neurasthenia, 353 

diagnosis, 354 

treatment, 354 
obstruction, 232 

acute, 232 

course, 253 

definition, 233 

diagnosis, 255 

etiology, 233 

location of the obstruc- 
tion, 257 

objective signs, 251 

pathological changes, 242 

recognition, 255 

recognition of the differ- 
ent forms, 261 

symptomatology, 244 

synonyms, 233 

treatment, 264 

treatment, medical, 264 

treatment, surgical, 272 
obstruction, chronic, 274 

complications, 282 

course, 283 

diagnosis, 283 

etiology, 274 

prognosis, 283 

symptomatology, 275 

treatment, 284 

treatment, surgical, 286 
parasites, 355 
vertigo, 307 
Intestine, anatomy of the, 1 
anaesthesia of the, 339 
compression of the, 233 
hyperesthesia of the, 339 
obturation of the, 239, 262 
paresthesia of the, 339 
strangulation of the, 234 
Intestines, motor neuroses of the, 
290 
neoplasms of the, 156 
nervous affections of the, 288 

classification, 289 
paralysis of the, 320 



Intestines, paralysis of the, diag- 
nosis, 321 
treatment, 321 
peristaltic restlessness of the, 

325 
secretory neuroses of the, 341 
sensory neuroses of the, 332 
ulcers of the, 133 
Intussusception, 240, 262 

agonal, 242 
Irrigator, Kemp's rectal, 82 

Jaffe, 259 
v. Jaksch, 54 
Jejunitis, acute, 92 
Jejunum, anatomy of the, 4 
Jurgens, 100 

Kahn, Arthur, 314 
Kartulis, 115, 116 
Kelly, 37 

Kelly's rectal speculum, 38 
Kelsey, 192 

Kemp's rectal irrigator, 82 
Kerkring's valves, 8 
Kittagawa, 345 
Klebs, 149 
Klemperer, 316, 317 
Klubbe, 268 
Koch, 115 
Kocher, 270 
Koenig, 275 
Korte, 271 
Kossobudskj, 190 
Kraus, 134 
Kruse, 118 
Kuhn, 44 
Kundrat, 177 

Kussmaul, 143, 267, 268, 315, 317, 
352 

Laboulbene, 343 
Lafleur, 116, 119, 122 
Lambl, 115 
Lange, F., 192, 198 



INDEX. 



393 



Langenbeck, 194 

Large bowel, physiology of the, 
18 
structure of the, 17 

intestine, anatomy of the, 11 
Lavage of the bowel, 48 

in intestinal obstruction, 
268 

of the stomach in intestinal 
obstruction, 267 
Laveran, 128 
Legueu, F., 228 
Leiclitenstern, 70, 232, 234, 301, 

373, 374, 376, 380 
Lemazurier, 306 
Lenander, 203 
Leube, 80, 139, 307 
Leubuscher, 315 
Leuckart, 362, 373, 383 
Levi, 306 

v. Ley den, 220, 344, 348 
Libman, 172 
Lieberkuhn's glands, 9 
Ligature in hemorrhoids, 193 
Limbourg, 22 
Lindberger, 22 
Lipoma of the intestines, 173 
Litten, 141 
Liver fluke, 368 
Loesch, 113 
Ludwig, 25 
Lusk, 19, 26 
Lutz, 373, 376, 385 
Lympho-sarcoma of the intestines, 
172 

Macfadyen, 20, 75 
Madelung, 173 
Malmsten, 357 
Marcy, H. O., 273 
Matterstock, 207 
Maggot- worm, 375 
Mannaberg, 76 

Massage in intestinal obstruction, 
269 



Massage in the treatment of con- 
stipation, 312 
of disease, 83 
Massaiutin, 116 
Massloff, 288 
Mathews, 93 
Mayer, 138 
Mayor, A., 93 
McBurney, 41, 203, 229 
McCosh, A. J., 229 
Meckel's diverticulum, strangula- 
tion by, 236 
Membranous diarrhoea, 341 
enteritis, 341 

' definition, 341 
diagnosis, 349 
etiology, 345 
history, 341 
symptomatology, 347 
synonyms, 341 
treatment, 350 
Mendelson, Walter, 345 
Mercury, metallic, in intestinal 

obstruction, 271 
Meteorism, 327 
diagnosis, 329 
etiology, 327 
prognosis, 329 
symptomatology, 328 
treatment, 329 
Meydl, 157 

Meyer, Willy, 229, 230 
Micro - organisms in the fasces, 

74 
Miller, 22 
Minich, 64 
Minkowski, 28, 47 
Miserere, 233 
Monti, 382 
Moreau, 286 
Morgagni, 342 
Morris, R T., 214, 228 
Mosler, 385 

Motion of the intestine, 28 
Motor function of the intestine, 



394 



INDEX. 



Einhorn's method of ascertain- 
ing, 62 

Mucin in the faeces, 53 

Mucous colic, 341 

Muller, Max, 158 

Munk, 25, 27 

Murphy, 228, 286 

Murphy's button, obturation by, 
240 

Musser, 116 

Myoma of the intestines, 173 

Nasse, 116 
Nematodes, 371 
Nencki, 19, 20, 75 
Neoplasms of the intestines, 156 
Nervous affections of the intes- 
tines, 288 
diarrhoea, 292 
Neuralgia, hypogastric, 338 

mesenterica, 332 
Neurasthenia, intestinal, 353 
Neuroses of the intestines, motor, 
290 
secretory, 341 
sensory, 331 
v. Noorden, C, 56, 350, 351 
Nothnagel, 28, 30, 77, 156, 172, 
203, 208, 220, 223, 226, 230, 241, 
275, 289, 291, 300, 308, 344, 348 
Nuttal, 75 

Obstipatio, 297 
Obstruction, intestinal, 232 
Obturation of the intestine, 239, 

262 
Oil injections in the treatment of 

constipation, 317 
Opium in intestinal obstruction, 

265 
Oppolzer, 336 
Osier, 116 

Oxyuris vermicularis, 375 
diagnosis, 377 
prophylaxis, 377 



Oxyuris vermicularis, symptoma- 
tology, 376 
treatment, 377 

Paget, 385 

Palpation, 40 

Pancreatic juice, digestive power 

of, 19 
Paresthesia of the intestine, 239 
Paralysis of the intestines, 320 
of the sphincters of the anus, 
323 

diagnosis, 324 

prognosis, 324 

treatment, 324 
Paramecium coli, 357 
Parasites, intestinal, 355 
Paratyphlitis, 202 
Parenski, 140 
Paresis of the sphincters of the 

anus, 323 
Pariser, 53, 345, 348 
Passio iliaca, 233 
Pean, 286 
Peiper, 385 

Penzoldt, 220, 225, 226, 230 
Peptone in the feces, 54 
Percussion, 44 

Peristalsis of the intestine, 28 
Peristaltic restlessness of the in- 
testines, 325 

definition, 325 

diagnosis, 326 

etiology, 325 

symptomatology, 325 

treatment, 326 
Perityphlitis, 202 
Petriquin, 226 
Pettenkofer, 57 
Peyer, 291 
Peyer's patches, 11 
Pfluger, 30 

Phlebectasia hemorrhoidalis, 175 
Pighead, 363 
Piles, 175 



INDEX. 



395 



Piles, arterial, 178 
capillary, 178 
venous, 179 
Pilliet, 144 
Pin-worm, 375 
Plica Douglasii, 15 
Poelchen, 150 

Polypi of the intestines, 173 
Pooley, 192 
Proctitis, 93 
Proctoscope, Tuttle's pneumatic, 

38 
Proctoscop}'. 37 
Proctospasmiis, 322 
diagnosis, 323 
treatment, 323 
Prolapse of the rectum, 195 
Propeptone in the faeces, 54 
Protozoa, 355 
Puncture of the bowel in intestinal 

obstruction, 270 
Purgatives in the treatment of 

constipation, 318 
Putrefaction of albuminates in the 

large intestine, 21 

Quincke, 50, 116, 288 

Racfiford, 19 

Rectal alimentation, 80 

bougies, 43 

electrode, 84 

specula, 37 
Rectum, anaesthesia of the, 339 

anatomy of the, 15 

prolapse of the, 195 
Reichmann, 39 
Ribbert, 204 
Riedel, 208, 230 
Rieder, 69 
Roentgen rays in examination of 

the bowel, 39 
Romberg, 338 
Rose, A., 269, 313 
Rosenbach, 46, 253 



Rosenheim, 105, 173, 314, 321, 325, 

329, 353 
Rosenstein, 25, 27 
Ross, 116 
Rothmann, 344 
Rotter, 203 
Round -worms, 371 
Roux, 192, 203 
Rubner, 27 
Ruedi, 303 
Runeberg, 46 
Rushmore, J. D., 273 

Sahli, 203, 223, 226, 313, 330 
Salmon, 193 

Sal vi <>li. 25 
Sands, 203 

Sarcoma of the intestines, 172 
Sasaki, 100 
Schiff, 28 

Schmidt, 51, 54, 58 
Schmidt's fermentation test, 55 
Schmidt-Miihlheim, 25 
Schmitz, 22 
Schnetter, 46 
Schoening, 156 
Schuberg, 116 
Scolecoiditis, 202 
Seat-worm, 375 

Secretory function of the intes- 
tines, 18 
neuroses of the intestines, 341 
Senator, 308 
Senn, 269 
Sennertws, 336 
Shiga, 117, 130 
Sieber, 20, 75 

Sigmoid flexure of the colon, 15 
Simon. 43 
Sims, 37 

Sims' rectal speculum, 37 
Siredey, F., 342, 350 
Small intestine, anatomy of the, 4 

structure of the, 6 
Sodre, 114, 120, 130 



396 



INDEX. 



Solitary follicles of the intestines, 

10 
Sonnenburg, 203, 220, 230 
Spasm of the rectum, 322 
Spasmodic contraction of the 

bowel, 301 
Specula, rectal, 37 
Spool-worm, 371 
Sporozoa, 356 

romanum, 15 
Starke, 134 
Stein, R, 230 
Stengel, 116 
Stercoral diarrhoea, 294 
Stewart, 273 
Stockton, 116 
Stokes, 226 
Stool, acholic, 58 
sieve, Boas', 60 
Einhoru's, 61 
Strangulation of the intestine, 

234 
Stricture of the rectum as a cause 

of chronic obstruction, 281 
Strong, 118 

Strongylus duodenalis, 378 
Subcutaneous alimentation, 80 
Sutton, E. M., 47 
Syms, Parker, 273 
Syphilitic ulcers, 149 



Thermocautery in the treatment of 

hemorrhoids, 194 
Thierfelder, 75 
Thread- worm, 375 
Thrombotic ulcers, 140 
Thrombus of the mesenteric veins, 

144 
Toxic ulcers, 150 
Transillumination of the bowel, 39 
Trastour, 2 

Treatment, methods of, 77 
Trematodes, 362, 368 

treatment, 371 
Treves, 198, 220, 242, 246, 265, 268, 

270, 272, 274, 276, 277, 287 
Trichina spiralis, 385 

S}nnptoms, 386 
Trichinosis, 386 

prophylaxis, 386 
treatment, 386 
Trichocephalus dispar, 383 
diagnosis, 383 
symptoms, 383 
treatment, 385 
Trichomonas intestinalis, 356 
Trousseau, 290 
Tuberculous ulcers, 146 
Tubular diarrhoea, 341 
Tuttle, 38 
Tympanites, 327 



Taenia cucumerina, 364 

diminuta, 365 

flavopunctata, 365 

lata, 363 

mediocanellata, 361 

nana, 364 

saginata, 361 

solium, 360 
Taeniae of the large intestine, 12 
Talamon, 203 
Tapeworms, 357 

prophylaxis, 365 

treatment, 365 
Tavel, 206 



Ulcer, duodenal, 133 
Ulcers, amyloid, 145 

embolic, 140 

of the intestines, 133 

syphilitic, 149 

thrombotic, 140 

toxic, 150 

tuberculous, 151 
Urobilin in the faeces, 57 

Valve, ileo-csecal, 13 

of Bauhin, 13 
Valvulse conniventes Kerkringi, 8 
Van Cott, 205, 207 



INDEX. 



397 



Vermes, 357 
Vermiform appendix, 13 
Verneuil, 191 
Vertigo, intestinal, 307 
Virchow, 145 
Voit, 19, 24, 26 
Volkmann, 168 
Volvulus, 238, 261 
Volz, 207, 226 



Wertheimer, 336 

Whip-worm, 383 

Whitehead, 195, 342, 350 

Wiggin, Fred. H., 273 

Willigk, 134 

Wilson, 206 

Wolf, H. J., 230 

Woodward, 86, 99, 275, 298, 342 

Worms, intestinal, 357 



Wallace, 325 
Weber, L., Ill 
Weigert, 344 
Weir, 203 



Zenker, 385 
Ziemssen, 45, 269, 270 
Zuckerkandl, 204 
Zunker, 356 



MAR 1 2 1904 



LIBRARY OF CONGRESS 



021 062 227 5 




